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(12) INTERNATIONAL APPLICATION PUBLISHED UNDER THE PATENT COOPERATION TREATY (PCT)

(19) World Intellectual Property Organization

International Bureau

(43) International Publication Date
2 August 2007 (02.08.2007)

PCT

(10) International Publication Number

wo 2007/087575 A2

(51) International Patent Classification:
A61K 31/192 (2006.01)

(21) International Application Number:

PCT/US2007/060995

(22) International Filing Date: 24 January 2007 (24.01.2007)

(25) Filing Language:

(26) Publication Language:

English
English

(30) Priority Data:

60/761,612
60/833,934

24 January 2006 (24.0 1 .2006) US
28 July 2006 (28.07.2006) US

(63) Related by continuation (CON) or continuation-in-part
(CIP) to earlier application:

US 60/761,612 (CON)

Filed on 24 January 2006 (24.01.2006)

(71) Applicant (fo r all designated States except US)i UNIVER-
SITY OF CfflCAGO [US/US]; 5801 S. Elhs, Chicago, IL
60637 (US).

(72) Inventors; and

(75) Inventors/Applicants (for US only): MAITLAND,
Mardi, Gomberg [US/US]; Chicago, IL (US). RATAIN,
Mark [US/US]; 1040 West Oakdale Avenue, Chicago, IL
60657 (US). GARCIA, Joe, GN [US/US] ; Chicago, IL
(US). MAITLAND, Michael [US/US]; Chicago, IL (US).
MORENO, Liliana [CO/US]; Chicago, IL (US).

(74) Agent: LANDRUM, Charles, P.; Fulbright & Jaworski
L.L.P., 600 Congress Avenue, Suite 2400, Austin, TX
78701 (US).

(81) Designated States (unless otherwise indicated, for every
kind of national protection available): AE, AG, AL, AM,
AT, AU, AZ, BA, BB, BG, BR, BW, BY, BZ, CA, CH, CN,
CO, CR, CU, CZ, DE, DK, DM, DZ, EC, EE, EG, ES, FI,
GB, GD, GE, GH, GM, GT, HN, HR, HU, ID, IL, IN, IS,
JP, KE, KG, KM, KN, KP, KR, KZ, LA, LC, LK, LR, LS,
LT, LU, LV, LY, MA, MD, MG, MK, MN, MW, MX, MY,
MZ, NA, NG, NI, NO, NZ, OM, PG, PH, PL, PT, RO, RS,
RU, SC, SD, SE, SG, SK, SL, SM, SV, SY, TJ, TM, TN,
TR, TT, TZ, UA, UG, US (patent), UZ, VC, VN, ZA, ZM,
ZW.

(84) Designated States (unless otherwise indicated, for every
kind of regional protection available): ARIPO (BW, GH,
GM, KE, LS, MW, MZ, NA, SD, SL, SZ, TZ, UG, ZM,
ZW), Eurasian (AM, AZ, BY, KG, KZ, MD, RU, TJ, TM),
European (AT, BE, BG, CH, CY, CZ, DE, DK, EE, ES, FI,
FR, GB, GR, HU, IE, IS, IT, LT, LU, LV, MC, NL, PL, PT,
RO, SE, SI, SK, TR), OAPI (BE, BJ, CF, CG, CI, CM, GA,
GN, GQ, GW, ML, MR, NE, SN, TD, TG).

Published:

— without international search report and to be republished
upon receipt of that report

For two-letter codes and other abbreviations, refer to the "Guid-
ance Notes on Codes and Abbreviations" appearing at the begin-
ning of each regular issue of the PCT Gazette.

IT)

<S| (54) Title: COMPOSITIONS AND METHODS FOR TREATING PULMONARY HYPERTENSION

(57) Abstract: Compositions and methods of the invention are related to treating pulmonary hypertension using a Raf kinase in-
hibitor, such as sorafenib. IQ a particular aspect, pulmonary hypertension is pulmonary arterial hypertension.

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DESCRIPTION

COMPOSITIONS AND METHODS FOR TREATING PULMONARY

HYPERTENSION

BACKGROUND OF THE INVENTION

This application claims priority to U.S. Provisional Patent applications serial number
60/761,612 filed January 24, 2006 and serial number 60/833,934 filed July 28, 2006, each of
which is incorporated herein by reference in its entirety.

I. FIELD OF THE INVENTION

The invention described herein is related generally to medicine and particularly
cardiac and puhnonary medicine. The invention is fiirther related to therapeutic and
prophylactic treatment of pulmonary hypertension and particularly pulmonary arterial
hypertension.

IT BACKGROUND

Pulmonary hypertension ("PH") refers to a disease characterized by sustained
elevations of puhnonary artery pressure (Rubin, 1997). Generally, a patient having a mean
pulmonary artery pressirre equal to or greater than 25 mm Hg with a pulmonary capillary or
left atrial pressure equal to or less than 15 mm Hg is characterized as having PH or as
symptomatic of PH. These parameters may be measured in the subject at rest by right-heart
catheterization. Pulmonary arterial hypertension ("PAH") includes idiopathic pulmonary
arterial hypertension; familial pulmonary arterial hypertension; pulmonary arterial
hypertension in the setting of connective tissue diseases (e,g., locahzed cutaneous systemic
sclerosis (CREST syndrome), diffuse scleroderma, systemic lupus er3^ematosus, mixed
connective tissue disease, and other less conmion diseases), portal hypertension, congenital
left-to-right intracardiac shunts, and infection with the human immunodeficiency virus); and
persistent pulmonary hypertension of the newborn. For a review of the mechanisms of
disease related to PAH see Farber and Loscalso (2004), which is incorporated herein by
reference in its entirety.

The World Health Organization (WHO) has classified pulmonary hypertension into
groups based on known causes. WHO group I includes patients with PAH including those

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patients with Idiopathic PAH; FamiUal PAH, and Associated PAH, wliich is related to certain
conditions including connective tissue diseases, congenital systemic-to-pulmonary-shunts,
portal hypertension^ HIV infection, dnigs and toxins, glycogen storage disease, Gaucher's
disease, hereditary hemorrhagic telangiectasia, hemoglobinopathies, myeloproliferative
5 disorders, splenectomy, and others; PAH associated with significant venous or capillary
involvement; and persistent pulmonary hypertension of the newborn. WHO group II includes
patients with pulmonary venous hypertension. WHO group III includes patients with
pulmonary hypertension associated with hypoxemia. WHO group IV includes patients with
pulmonary hypertension due to chronic thrombotic disease, embolic disease or both. Finally,
10 WHO group V includes patients with pulmonary hypertension due a variety of miscellaneous
conditions.

The WHO also classifies pulmonary hypertension into functional groups based on
their exercise capacity and symptoms. WHO class I includes patients with PAH without
limitations of physical activity. WHO class II includes patients with PAH resulting in slight
15 limitation of physical activity. WHO class III includes patients with PAH resulting in
marked limitation in physical activity. WHO class IV includes patients with PAH that are
unable engage in physical activity without maaifesting symptoms.

As stated above, PH is also associated with disorders of the respiratory system and/or
hypoxemia, including chronic obstructive pulmonary disease^ interstitial lung disease, sleep-
20 disordered breathing, alveolar hypoventilation disorders, chronic exposure to high altitude,
neonatal lung disease and alveolar-capillary dysplasia (Humbert, 2004). PH is associated
with chronic thrombotic disease, embolic disease or both, and with a variety of miscellaneous
conditions.

Based on the inadequate therapies available, a need remains for additional safe and
25 effective methods of treating and managing PH.

SUMMARY OF THE INVENTION

The present invention includes the use of sorafenib, an inhibitor of multiple kinases
important to angiogenesis (Raf-1, VEGFR-2, VEGFR-3, PDGFR-p) shown to have
anticancer properties^ and sorafenib like compounds as an effective agent or therapy for
30 reducing pulmonary arterial pressure or a symptom of pulmonary arterial pressure. The
inventors contemplate using other inhibitors of angiogenesis or of VEGFR for reducing

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pulmonary arterial pressiore or a syinptom of pulmonaay arterial pressure. The invention
concerns therapeutic and preventative compositions and methods related to the various WHO
groups of pulmonary arterial hypertension (PAH) (e.g,, group I that includes idiopathic
pulmonary arterial hypertension (EPAH) and familial pulmonary arterial hypertension
5 (FPAH)), and Associated PAH, with the others in WHO group I. In certain embodiments,
PAH may be limited to a specific type of PAH. In certeiin embodiments the methods can
include providing a VEGFR2 inhibitor (z.e., sorafenib like compounds) to a subject with
pulmonary arterial hypertension (PAH)^ with symptoms of PAH^ or at risk for PAH, The
VEGFR2 inliibitor can include abt-869, amg706, AZD2171, bay57-9352, sorafenib, XL647,
10 XL999, GW786034, bevacizumab, PKC412, AEE788, PTK787 (vatalanib), OSI-930, OSI-
817, SU11248, AG-013736, ZK3-4709, quinazoline ZD6474, pyrrolocarbazole CEP-7055, or
CP-547632.

The present invention, in some embodiments, concerns methods that include
providing a kinase inhibitor, such as sorafenib, to a subject with pulmonary arterial

15 hypertension (PAH), with symptoms of PAH, or at risk for PAH. The term "provide," and
other related forms of the term, is used according to its ordinary meaning of to supply or to
furnish, which may be accomplished directly or indirectly. It is contemplated that the patient
may be provided sorafenib or other kinase inhibitor directly, such as by administering or
prescribing, for example, sorafenib or a pharmaceutically acceptable salt thereof, or

20 indirectly, such as by administering or prescribing a sorafenib prodrug or a pharmaceutically
acceptable salt thereof, such that the subject is effectively provided with sorafenib.

In some embodiments, the patient has a mean puhnonary artery pressure equal to or
greater than 25 mm Hg with a pulmonary capillary or lefL atrial pressure equal to or less than
15 nam Hg, and/or a pulmonary vascular resistance greater than or equal to 2 Wood Units.

25 Pulmonary Vascular Resistance (PVR) is the general pressure load against which the right
ventricle must pump to push blood through the lungs. PVR is typically expressed in Wood
units which is defined by the formula: PVR = (MPAP minus PCWP) divided by cardiac
output (CO). Less than 2 Wood Units equals the PVR of an average healthy person, z.e.,
MPAP is about 20 mmHg; LAP is about less than or equal to 15 mmHg; CO is about 5 liters

30 per minute. MPAP is tiie Mean Average Pulmonary Artery Pressmre which is the average
pressure in the pulmonary artery. MPAP can be calculated using the formula: [(2 times
diastolic pulmonary artery pressure (DPAP) plus systolic pulmonary artery pressmre (SPAP)]

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divided by 3, with the normal MPAP range tjApically being between 10 to 20 mmHg. PCWP
is the Pulmonary Capillary Wedge Pressure which is an indirect measurement of pressure in
the heart's left atrium which can be directly monitored during pulmonary catheterization. The
normal PCWP range is typically between 5 to 15 mmHg. CO is the volume of blood ejected
5 by the heart per minute and can be calculated by the formula: CO (in liters/minute) equals
heart rate (in beats/minute) times stroke volume (in liters/beat). The normal CO range is
between 4 to 8 L/min. Normal PVR is typically considered between 0.7 to 2.0 Wood units.
These parameters may be measured in the subject at rest by right-heart catheterization.

The term "administering" is used according to its ordinary meaning of to dispense,
10 furnish, supply, or give, ha many embodiments of the invention, the subject may administer
sorafenib to themselves or a medical practitioner may provide the sorafenib to the subject.
The term "prescribing" is used according to its ordinary meaning of to advise or order the use
of, and it is generally contemplated that a medical practitioner would prescribe the sorafenib
to the subject, which the subject would then administer to themselves. It is contemplated that
15 any embodiment in which sorafenib is provided to a subject may be implemented in the
context of administering or prescribing sorafenib, a sorafenib prodrugs or a pharmaceutically
acceptable salt thereof

In further embodiments, it is contemplated that the subject is provided an amount of
sorafenib that is effective to treat or prevent PAH. It is contemplated that the term '"treat" is

20 used according to its ordinary meaning of to deal with a disease or affection, a part of the
body, or a person in order to relieve or cure. Patients who have PAH or symptoms of PAH
may be treated according to methods of the invention. It is further contemplated that
treatment may include management of PAH or PAH symptoms, which means that treatment
allows PAH or PAH symptoms to be controlled. The term ''prevent" is used according to its

25 ordinary meaning of to preclude, stop, or hinder. It is contemplated that an "effective
amoimf is an amount that achieves the stated goal, which may be treatment and/or
prevention of PAH* It is contemplated that in the context of treatment an effective amount
produces a therapeutic benefit^ which includes, but may not be necessarily limited to the
following characteristics with respect to pulmonary arterial h3pertension: reducing mean

30 pulmonary pressure, increasing cardiac output/cardiac index measured by either
thermodilution or Fick, improving timed walk distance (e.g., six-minute walk), improviag
metabolic equivalents (MET) (e.g-., exercise treadmill test), reducing anginal pain frequency.

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reducing dyspnea, synocope, presyncope, symptoms of right heart failure including edema
and ascites, preventing need for lung or heart transplant, reducing length of stay in intensive
care, reducing length of stay in hospital, or prolonging life.

Typically, a patient or subject is assessed by using the six-minute wallc test. The test
5 is administered by preparing an unobstructed path of a Icnown distance, e.g., path of 50 feet
(100 feet round-trip). A chair may be placed at each end of path. The patient is typically
instructed to walk at his/her own pace and stop to rest if needed and to cover as much
distance as possible. Typically, one would look for improvement between pretreatment
assessment and post treatment assessments. The six minute walk distance may also be
10 compared to distances walked by a comparable healthy population, typically by using
equations from a published study of healthy people of the same age group, hnprovement in a
patient's or subject's condition may be indicated by an increased six minute walk distance.

Another method of assessing a patient or subject is the determination of tricuspid
valve regurgitation velocity. Tricuspid valve regurgitation velocity is typically assessed by

15 an echocardiogram, in particular Doppler echocardiograms. The trained sonographer
possesses the requisite knowledge to carry out the echocardiograms in association with
assessment by a qualified physician or technician for assessment. A typical
echocardiographic imaging protocol includes a parasternal long-axis view; parasternal short-
axis views at the aortic valve, mitral valve, and left ventricular levels; and apical 4-chamber,

20 2-chamber, and long-axis views. Mitral, aortic, pulmonic and tricuspid valves can be imaged
by color Doppler in multiple views to determine the degree of regurgitation. Measurements
of various cardiac dimensions are performed according to American Society of
Echocardiography convention. Pulmonary artery systolic pressure can be calculated utilizing
a modified Bernoulli equation, PAP == 4v^4-RAP, where v = peak systolic velocity or tricuspid

25 regurgitation jet recorded by continuous wave Doppler and RAP (right atrial pressure) is
assumed to be 10 mmHg. Visual estimates of left ventricular ejection fraction can be made
by integrating information from all views and left ventricular ejection fraction is considered
normal if above 0.50, Improvement in a patient's or subject's condition may be indicated by
a decrease in tricuspid valve regurgitation, as well a upgrading in the WHO fimctional class

30 designation.

In certain embodiments, the subject's mean pulmonary artery pressure is reduced to
less than 25 mm Hg It is specifically contemplated that the subject may experience a

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reduction in his mean pulmonary artery pressure of about, at least about, or at most about 1,
2, 3, 4, 5, 10. 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75 or greater percent, or any range
derivable therein, relative the value prior to treatment with sorafenib, therein, relative the
value prior to treatment with sorafenib. Such measurements may be taken at rest using a
right heart catheterization, though other methods may be used.

Therefore, the present invention specifically includes methods for treating or
preventing PAH in a patient comprising providing to the patient an effective amount of
sorafenib or a pharmaceutically acceptable salt thereof Subjects and patients specifically
include humans, in addition to other mammals.

In some methods of the invention may fiirther include identifying a subject with PAH
or symptoms of PAH or a patient at risk for PAH. This may be achieved by a number of ways
knovm to those of skill in the art, including, but not necessarily limited to, taking a patient
history, inquiring about family members with PAH, obtaining the level of pressure in the
subject's pulmonary artery, identifying in the subject risk factors for PAH, assessing an
electrocardiogram of the subject, assessing an echocardiogram of the subject, assessing
pulmonary function tests (PFTs) of the patient, assessing a perfiision lung scan, a high
resolution CT scan of the chest and assessing a right-heart cardiac catheterization with
vasodilatory testing.

In some embodiments of the invention, the subject has been diagnosed as having
Class I, II, III, or IV PAH according to guidelines used for class diagnosis, such as by tlie
New York Heart Association or as having Class I, II, III, or IV, such as by the World Health
Organization. See Rubin, 2004, which is hereby incorporated by reference. The term "severe
PAH" refers to Class 3 or 4 or Class III or IV, according to the relevant guidelines.

In further embodiments of the invention, after the subject has taken or been given
sorafenib or a sorafenib prodmg, he/she experiences a reduction in pulmonary pressure. In
some methods of the invention the reduction is about, about at least or about at most a
reduction of 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90 percent, or any
range derivable therein, relative the pressure prior to sorafenib intake. In other embodiments,
there is a fall of mean pulmonary artery pressiu*e of at least about 10 ram Hg after treatment
with sorafenib. It is contemplated that the fall may be about, at least about, or at most about.

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10, 15, 20, 25, 3O5 35, 40, 45, 50 mm Hg^ or any range derivable therein, after or during
sorafenib treatment.

In further embodiments, methods involve evaluating PAH in the subject before and/or
after the subject has taken or been given sorafenib. This can be achieved by a number of
5 ways that include, but are not necessarily limited to, having an electrocardiogram, an
echocardiogram, pulmonary function tests (PFTs), a perfiasion lung scan, other vasodilator
testing, and/or a right-heart cardiac catheterization.

The present invention also relates to methods in which a subject is administered or
prescribed multiple doses of sorafenib. The subject may take or be given 2, 3, 4, 5, 6, 7, 8, 9,

10 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 25, 30, 35, 40, 45, 50, 100, 200, 300, 400, (twice
daily- oncologic dose), 500 doses or more of sorafenib. It is also contemplated that a subject
may be given or prescribed sorafenib indefinitely or for a set period of time, such as 1,2, 3, 4,
5, 6, 7 days, 1, 2, 3, 4, 5, weeks, 1, 2, 3, 4, 5, 6, 7, 8, 9 10, 11, 12 months, and/or 1, 2, 3, 4, 5,
6;, 7, 8, 9, 10 years or more, or any range derivable therein. Alternatively, it is contemplated

15 that a patient continues to be prescribed or administered sorafenib until the subject can be
classified as a Class 1 or 2 subject (or Class I or 11), the six mile walk distance is increased,
the symptoms of PAH are relieved or reduced (such as triscuspid valve regurgitation), the
mean pulmonary artery pressure is reduced to less than about 25 mm Hg or there is an
improvement with respect to PAH or a symptom of PAH, such as a relative decrease or

20 increase in the value of a measurement of about, at least about, or at most about 2, 3, 4, 5, 6,
7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 76, 80,
85, 90, 95, 100 or more percent or —fold, or any range derivable therein, as compared to a
value of a measurement prior to or during sorafenib therapy.

hi embodiments of the invention^ a single dose of sorafenib is between about 50 mg
25 and about 400 or 600 mg twice daily of sorafenib, whereas a dose refers to a single,
uninterrupted administration of sorafenib. A dose may be about, at least about, or at most
about 0,1, 0.5, 1, 2, 3, 4, 5,-6, 7, 8, 9, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80,
85, 90, 95, 100, 125, 150, 175, 200, 225, 250, 275, 300, 325, 350, 375, 400, 425, 450, 475,
500, 525, 550, 575, 600, 625, 650, 675, 700, 725, 750, 775, 800, 825/850, 875, 900, 925,
30 950, 975, 1000 mg or mg/kg, or any range derivable therein. It is contemplated that a dosage
of mg/kg refers to the mg amormt of sorafenib per kg of total body weight of the subject. It is

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contemplated that when multiple doses are given to a patient^ the doses may vary in amount
or they may be the same.

Sorafenib may be introduced into a subject by a number of ways that include, but are
not necessarily limited to, orally, intravenously, intraarterially, or inhalation.

5 The present invention also covers methods that also include administering or

prescribing at least a second PAH treatment (''secondary PAH treatment"). Other compounds
or agents that have been used to treat PAH include, but are not limited to the following: an
anticoagulant (such as Coumadin or Warfarin), an calcium channel blocker (such as
amlodipine, diltiazem, nifedipine, felodipine, isradipine, nicardipine, or verapamil), a

10 prostacyclin (such as epoprostenol, treprostinil, iloprost), nitric oxide (only used in acute
settings), a diuretic, a cardiac glycoside (digoxin), an endothelin antagonist (including non-
selective inhibition with bosentan), a phosphodiesterase inhibitor (such as sildenafil), an
endopeptidase inhibitor, a lipid lowering agents a thromboxane inhibitor (such as terbogrel),
or oxygen. It is contemplated that a combination of treatments that include sorafenib maybe

15 employed including investigational agents such as sitaxentan and ambrisentan (selective
endothelin antagonist), and tadalafil (long acting phosphodiesterase inhibitor). A description
of different therapies is provided in Badesch et ah^ 2004, which is hereby incorporated by
reference.

In certain embodiments, the sorafenib or composition containing sorafenib, or a
20 secondary PAH treatment may be administered or prescribed before, after, or during surgery.
In some embodiments, the surgery is lung transplantation, in which case other treatment is
not subsequently needed.

Other embodiments of the invention include a pharmaceutical composition
comprising sorafenib or a pharmaceutically acceptable salt thereof and at least a second PAH
25 treatment, such as those discussed above.

Any embodiment discussed with respect to one aspect of the invention applies to
other aspects of the invention as well. It is further contemplated that embodiments discussed
in the context of PAH may be applied in the context of PH, and vice versa.

The embodiments in the Example section are understood to be embodiments of the
30 invention that are applicable to all aspects of the invention.

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The use of the term "or" in the claims is used to mean "and/or" unless explicitly
indicated to refer to alternatives only or the alternatives are mutually exclusive^ although the
disclosure supports a definition that refers to only alternatives and "and/or/'

Throughout this application, the term "about" is used to indicate that a value includes
5 the standard deviation of error for the device or method being employed to determine the
value.

Following long-standing patent law, the words "a" and "an/' when used in
conjunction with the word "comprising" in the claims or specification, denotes one or more,
unless specifically noted,

10 Other objects, features and advantages of the present invention will become apparent

from the following detailed description. It should be imderstood, however, that the detailed
description and the specific examples, while indicating specific embodiments of the
invention, are given by way of illustration only, since various changes and modifications
within the spirit and scope of the invention will become apparent to those skilled in the art

1 5 from this detailed description.

DESCRIPTION OF THE DRAWINGS

So the above-recited features, advantages, and objects of the invention, as well as
others, will become clear and can be understood in detail, more particular descriptions and
certain embodiments of the invention briefly summarized above are illustrated in the
20 appended drawings. These drawings form a part of the specification. It is to be noted,
however, that the appended drawings illustrate or are associated with certain embodiments of
the invention and therefore are not to be considered limiting in their scope.

FIGs. 1 A-IB FIG. lA Shows pulmonary arterial pressure (mm Hg) of Dahl Salt
Sensitive (SS) rats under normoxic conditions, hypoxic conditions (10% FiOa), hypoxic
25 conditions and SU5416 administration, hypoxic conditions and sorafenib administration, and
hypoxic conditions and SU5416 and sorafenib administration. FIG. IB shows effects of
Sorafenib on pulmonary artery pressures and remodeling in rodent PH. Sorafenib prevents
hypoxia+Su5416 induced pulmonary HT and remodeling.

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FIG. 2 Shows right ventricle systolic pressiire (mm Hg) of Dahl SS rats under
normoxic conditions, hypoxic conditions, hypoxic conditions and SU5416 administration,
hypoxic conditions and sorafenib administration, and hypoxic conditions and SU5416 and
sorafenib administration.

5 FIG. 3 Shows hematocrit % in Dahl SS rats under normoxic conditions, hypoxic

conditions^ hypoxic conditions and SU5416 administration, hypoxic conditions and sorafenib
administration, and hypoxic conditions and both SU5416 and sorafenib administration.

FIGs, 4A-4B Show right ventricular/left ventricular 4- septum ratio values, in Dahl SS
rats under normoxic conditions, hypoxic conditions, hypoxic conditions and SU5416
10 administration, hypoxic conditions and sorafenib administration, and hypoxic conditions and
SU5416 and sorafenib administration. Sorafenib prevented hypoxia+SU5416 development of
right heart hypertrophy (RV/LV4-Septum) in Dahl SS rats,

FIG. 5 Shows mean blood pressure (nmi Hg) of Dahl SS rats under normoxic
conditions, hypoxic conditions, hypoxic conditions and SU5416 administration, hypoxic
15 conditions and sorafenib admirustration, and hypoxic conditions and SU5416 and sorafenib
administration.

FIG. 6 Shows echocardiographic data on the calculated left ventricle mass (grams) of
Dahl SS rats under normoxic conditions, hypoxic conditions, hypoxic conditions and SU5416
administration, hypoxic conditions and sorafenib administration, and hypoxic conditions and
20 SU5416 and sorafenib administration.

FIG. 7 Shows echocardiographic data on the calculated aortic cardiac output (1/min)
of Dahl SS rats under normoxic conditions, hypoxic conditions, hypoxic conditions and
SU5416 administration, hypoxic conditions and sorafenib administration^ and hypoxic
conditions and SU54I6 and sorafenib administration.

25 FIG. 8 Shows echocardiographic data on the calculated pulmonary arterial pressure

gradient (mm Hg) of Dahl SS rats under normoxic conditions, hypoxic conditions, hypoxic
conditions and SU5416 administration, hypoxic conditions and sorafenib administration, and
hypoxic conditions and SU5416 and sorafenib administration.

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FIG. 9 Shows echocardiographic data on the calculated right ventricle free wall
thickness of Dahl SS rats under normoxic conditions, hypoxic conditions, hypoxic conditions
and SU5416 administration, hypoxic conditions and sorafenib administration^ and hypoxic
conditions and SU5416 and sorafenib administration.

5 FIG. 10 Shows echocardiographic data on the calculated pulmonary arterial pressure

(mm Hg) of Dahl SS rats under normoxic conditions, hypoxic conditions, hypoxic conditions
and SU5416 administration, hypoxic conditions and sorafenib administration, and hypoxic
conditions and SU5416 and sorafenib administration.

FIG. 1 1 Shows echocardiographic data on the calculated right ventricle thickness (cm)
10 of Dahl SS rats under normoxic conditions, hypoxic conditions, hypoxic conditions and
SU5416 administration, hypoxic conditions and sorafenib administration, and hypoxic
conditions and SU5416 and sorafenib administration.

FIGs. 12A-12B Show VEGFR-2 immuno staining of endothelial cells (arrows)
occluding the lumen of a small pulmonary artery of SU5416 treated lung (rat) exposed to
15 chronic hypoxia for 3 weeks (600X) (FIG. 12 A). Smooth Muscle Cell alpha actin
immuno staining of a patent intra-alveoloar pulmonary artery of SU5416 treated lung (rat)
exposed to chronic hypoxia for 3 weeks. Note that the precapillary vessel has acquired a
well-defined medial smooth muscle cell layer (600X) (FIG. I2B).

FIG. 13 Shows human pulmonary arteries demonstrating medial hypertrophy, intimal
20 thickening, neomuscularization, and thrombin deposition (clot).

FIG. 14 Shows a time course of clinical status, exercise, and hemodynamic before and
after initiation of imatinib treatment. The figure demonstrates the improvement in functional
class 6MW distance and decrease in pulmonary vascular resistance (patient had a decrease in
both mean PAP and an increase in cardiac index). (Ghofrard et aL^ 2005)

25 FIGs. 15A-15B Representative photomicrographs of rat lung at 21 days.

Hematoxylin +-Eosin stained (H&E) sections (1 OX). A. Hypoxia + SU54 16 and B. Hypoxia
4- SU5416 + Sorafenib.

FIG. 16 Shows histopathology of rat lung under normoxia. Hypoxia, Hypoxia +
SU5416+ Sorafenib, Hypoxia + Sorafenib, and Hypoxia + SU5416. The sections show

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remodeling of the lung vasculature in injiired animals (Hypoxia-i-SU5416) and a dramatic
improvement in rats that received daily sorafenib (Hypoxia -h SU5416+ Sorafenib), almost to
Normoxia controls

FIG. 17 Shows the Heath-Edwards grading of animals under normoxia. Hypoxia;,
5 Hypoxia -I- SU5416 + Soarfenib, Hypoxia + Sorafenib, and Hypoxia + SU5416. The Heafli-
Edwards grading system grades pulmonary hypertension by microscopic features. The
general classification is as follows:

Potentially Reversible ~ grade I Hypertrophy of the media of muscular pulmonary
arteries. Extension of muscle into the wall of pulmonary arterioles; grade II Muscle
10 . hypertrophy plus proliferation of intimal cells in arterioles and small muscular arteries; grade
III Muscle hypertrophy plus subendothelial fibrosis. Eventually, concentric masses of fibrous
tissue and reduplicated internal elastic lamina occlude the vascular lumen of arterioles and
small muscular arteries. Large elastic arteries show atherosclerosis

Usually Irreversible — grade IV Muscle hypertrophy is less apparent; progressive
15 dilatation of small arteries^ especially those near vessels with intimal fibrous occlusion.
Plexiform lesions occur; grade V Plexiform and angiomatoid lesions plus intra-alveolar
hemosiderin-fiUed macrophages; grade VI Necrotizing arteritis with thrombosis. Fibrinoid
necrosis of the arterial wall with a transmural infiltrate of polymorphonuclear leukocytes and
eosinophils,

20 DETAILED DESCRIPTION OF THE INVENTION

Pulmonary arterial hypertension is an angiogenic proliferative vasculopathy resulting
from abnormal endothelial and smooth muscle cell interactions. Over time, the vasculopathy
causes a narrowing of the pulmonary artery and its branches, resulting in right heart failure
and death. Therapies are directed primarily at dilating the narrowing vessels, and include:

25 prostacyclins (epoprostenol, treprostinil, and iloprost), endothelin receptor blockers
(bosentan^ sitaxsentan and ambrisarten^ which is in the FDA approval process)^ and
phosphodiesterase inhibitors (sildenafil and tadalafil (investigational). All currently FDA-
approved therapies improve six minute walk distance, (average 30 meters) with minimal
change in hemodynamic measurements and only epoprostenol has a proved survival benefit.

30 Drugs that inhibit processes important to pathological blood vessel branching and growth,
represent a new class of therapeutic agents for pulmonary arterial hypertension.

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Sorafenib is a bi-aryl urea that inliibits Raf-1 kinase, a regulator of endothelial
apoptosis, VEGFR-2, PDGFR-P, and VEGFR-3, growth factor receptors necessary for
angiogenesis, affecting vascular permeability and vessel stabilization through pericyte
recruitment and maturation. The inventors have designed and executed a three week study to
5 assess the safety and therapeutic activity of sorafenib in a hypoxia-induced model of
pulmonary hypertension in Dahl SS rats. A compound with a reportedly more limited
spectrum of kinase inhibitory activity, SU5416, was previously demonstrated to exacerbate
pulmonary hypertension in hypoxic rats.

Pulmonary hypertension refers to elevated blood pressure in the pulmonary
10 circulation. Pulmonary hypertension can be either primary or secondary to pulmonary or
cardiac disease. Typically, the pulmonary blood pressure in humans suffering from
pulmonary hypertension is greater than a mean pulmonary artery pressure of 25 mm Hg. The
common symptoms of PAH include dyspnea, fatigue, weakness, chest pain, recurrent
syncope^ seizures^ light-headedness, neurologic deficits, leg edema and palpitations (Rich,
15 1987; The Merck Manual 1999).

One embodiment of the invention encompasses methods of treating, pallating^
preventing, and/or managing PAH by administration to a patient in need of such treatment,
prevention, or management a therapeutically or prophylactically effective amount of
sorafenib, or a phannaceutically acceptable derivative or prodrug thereof.

20 As used herein, and unless otherwise indicated, the terms "pulmonary arterial

hypertension," "PAH" and pulmonary hypertension "PH" and related disorders include, but
are not limited to: Idiopathic PAH; Familial PAH, and Associated PAH, which is related to
certain conditions including connective tissue disease, congenital systemic-to-pulmonary-
shunts, portal hypertension^ HIV infection, drags and toxins, glycogen storage disease,

25 Gaucher' s disease, hereditary hemorrhagic telangiectasia, hemoglobinopathies,
myeloproliferative disorders, splenectomy, and others; PAH associated with significant
venous or capillary involvement; and persistent pulmonary hypertension of the newborn. It is
contemplated that embodiments discussed in the context of PAH may be applied in the
context of PH, and vice versa.

30 The term "prodrug" as used in this application refers to a precursor or derivative form

of a pharmaceutically active substance that is capable of being enzymatically or non-
13

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enzyiTLatically activated or converted into the more active parent form. See, e.g., Wilman
(1986) and Stella et aL (1985). In certain aspects^ a prodrug is less cytotoxic^ has a longer
half-life, may be targeted to a particular tissue and/or is more stable than the parent drug. For
example, an amide group of sorafenib can be derivatized to a hydroxyalkyl or
5 acycloxym ethyl derivative or other chemically appropriate derivative. The hydroxyalkyl may
then be converted non-enzymatically to render sorafenib. The acycloxymethyl group can be
acted upon by an esterase, vv^hich is then followed by a non-enzymatic conversion to
sorafenib.

Another embodiment of the invention encompasses a method of treating, preventing
10 and/or managing PH, which comprises administering or prescribing to a patient in need of
such treatment, prevention and/or management a therapeutically or prophylactically effective
amount of sorafenib, or a pharmaceutically acceptable salt or prodrug thereof, and a
therapeutically or prophylactically effective amount of a second agent.

Examples of second agents include^ but are not limited to^ anticoagulants ^ diuretics,
15 cardiac glycosides, calcium chamiel blockers, vasodilators, prostacyclin analogues,
endothelin antagonists, phosphodiesterase inhibitors, endopeptidase inhibitors, lipid lowering
agents, thromboxane inhibitors, or other agents found, for example, in the Physician*s Desk
Reference 2003. Second agents can be large molecules {e,g,^ proteins) or small molecules
{e.g.^ synthetic inorganic, organometallic, or organic molecules). Examples of specific
20 second agents include, but are not limited to, amlodipine, diltiazem, nifedipine, adenosine,
epoprostenol (Flolan®), treprostinil (Remodulin®), bosentan (Tracleer®), warfarin, digoxin,
nitric oxide, L-arginine, iloprost, betaprost, and sildenafil (Viagra®),

Another embodiment of the invention encompasses a method of reversing, reducing
or avoiding an adverse effect associated with the administration of a therapeutic used to treat
25 PH, which comprises administeringor prescribing to a patient in need thereof a
therapeutically or prophylactically effective amount of sorafenib, or a pharmaceutically
acceptable salt or prodmg thereof, and an optional second agent.

Procedures such as lung transplantation may be necessary to treat PH patients who
have failed to respond to medical therapy. It is believed that the combined use of sorafenib
30 and lung transplantation in a patient suffering from PH can be beneficial. It is believed that
sorafenib can work in combination with transplantation therapy, reducing complications such

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as chronic rejection and opportunistic infections associated with the transplantation.
Therefore, this invention encompasses a method of treating or managing PH, which
comprises administering to a patient (e.g.^ a human) sorafenib, or a pharmaceutically
acceptable salt or prodrug thereof, before, during, or after transplaatation therapy.

5 Certain aspects of the invention encompass pharmaceutical compositions that can be

used in methods of the invention. Specific compositions comprise sorafenib., or a
pharmaceutically acceptable salt or prodrug thereof, and an optional second agent.

Also encompassed by the invention are single unit dosage forms of sorafenib, or a
pharmaceutically acceptable salt or prodmg thereof.

10 Other aspects of the invention can encompass kits which comprise sorafenib, or a

pharmaceutically acceptable salt or prodrug thereof, and a second agent. For example, a kit
may contain the compound of the invention, and calcium channel blockers, vasodilators,
prostacyclin analogues, endothelin antagonists, phosphodiesterase inhibitors, endopeptidase
inhibitors, lipid lowering agents, thromboxane inhibitors or other agents used to treat PAH

15 patients.

As part of the spectrum of sorafenib's pharmacologic activity overlaps with SU5416,
a study was performed to determine whether sorafenib had similar effects or with additional
mechanisms of inhibitory activity could counteract the effects of SU5416, Dahl Salt
Sensitive rats were divided into 5 groups: normoxia + vehicle (normal, healthy control),

20 hypoxia + SU5416 (positive control), hypoxia + sorafenib (safety comparison with SU5416),
and hypoxia + sorafenib + SU5416 (therapeutic activity assessment). Echocardiograms were
performed on all rats at the start of the study. Except for the nomioxia group, all rats were
maintained in a hypoxia chamber with a partial pressure of oxygen of 10% FiOa for the
duration of the study. Rats in the two SU5416 groups received one subcutaneous injection of

25 SU5416 at the start of the study (20 mg/kg). Stock sorafenib solutions were prepared every
three days, crushing and dissolving sorafenib tablets in EL/ethanol (50:50; Sigma Cremophor
EL, 95% ethyl alcohol) at final concentration of 4 mg/mL, protected from light exposure and
stored at room temperature. Final dosing solutions were prepared on the day of use by
dilution of the stock solution to 1 mg/mL with water and administered by gavage to the rats

30 daily. After 3 weeks, all rats had echocardiography and hemodynamic studies. Organ and
blood specimens were obtained for further evaluation. Echocardiography images were

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obtained with short axis views demonstrating RV wall thickness when comparing Hypoxia +
SU5416 4- sorafenib; Hypoxia + SU5416; and Control- Normoxia. RV 3DE measurements
were also determined (diameters + area). A— RV major diameter, B= RV annulus diastolic
diameter & area, C= RV at 1/3 RV major diameter & area, D — RV at 2/3 RV major diameter
5 & area.

10 significant change in pressures or weights in rats given hypoxia plus sorafenib, Sorafenib
appears to have a beneficial effect on pulmonary hypertensive rats as rats in hypoxia^ plus
SU5416, plus sorafenib had pressures and weights similar to normoxia. The small sample
size did not allow for significant change in echocardiographic data but there appeared to be a •
positive trend with this combination. Pathologic specimen results are pending. Based on

15 these results the experiments were repeated with 18 rats distmbuted in the same 5 groups
(only difference was 3 additional rats in the normoxia group control group). The results were
reproducible. In the initial experiment two rats died during induction of anesthesia for
echocardiographic analysis (after unblinding-normoxia, hypoxia/SU5416). In the subsequent
experiment, one rat died on day zero (after imblinding- 1 hypoxia/sorafenib on day three).

20 These data suggest that sorafenib is a safe, therapeutic agent for the treatment of human
pulmonary hypertension. Below are the results of the 2 experiments as one cohort. Also see
FIGs. 1-1 L

Table 1. Pressures derived firom SU5416+sorafenib study - 3 1/2 Wk Hypoxia + Sorafenib
(Daily 2.5 mg/Kg) SU5416 (day zero 20 mg/kg i.p.)

PA mmHg
(+/-) SE

RVSPmmHg

(+/-) SE

RV/LV kg
SE

BPmmHg
{+/-) SE

Normoxia Vehicle

12+/-2

11+/-3

0.173+/-0.007

82+/-8

Hypoxia

22+/-1

20+/-2

0,262+/-0.023

94+/-4

Hypoxia-i-S U541 6

33+/-3

30+/-4

0.389+/- 0-02

78+/-4

Hypoxia +Sorafenib

1 S+/-2

1 1+1-2

0.248+^ 0.02

97+/-4

Hypoxia +Sorafenib+
SU5416

19+/-2

1 7+/-3

0.202+/- 0.015

108+/-10

Sorafenib appears to protect SU5416-treated hypoxia-exposed rats from pulmonary
arterial hypertension. Furthermore^ while sorafenib and SU5416 share some pharmacological

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activity^ unlike SU5416 sorafenib does not exacerbate hypoxia-induced hypertension. These
data suggest that sorafenib is safe and a potential therapeutic agent for the treatment of
human pulmonary hypertension.

III. COMPOUNDS OF THE INVENTION

5 Sorafenib is a small molecule inhibitor of Raf kinase and Raf associated signaling

pathways, including extracellular regulated kinases (ERKs). Sorafenib is also known as BAY
43-9005^ its anti-cancer properties are described in US Patent Publication 20030125359,
which is incorporated herein by reference. Sorafenib is known to target both the
Raf/MEK/ERK signaling pathway inhibiting cell proliferation and the VEGFR-2/PDGFR-P
10 pathway inhibiting angiogenesis. Sorafenib is currently being tested in the United States by
Bayer/Onyx in phase III clinical trials for advanced renal cell carcinoma. Methods for the
preparation of sorafenib and its related compounds is described in U.S. Patent Publication
number 2001/0027202 and 2003/0139605, which are incorporated herein by reference in their
entirety.

1 5 A. Tyrosine kinase / VEGFR inhibitors

A number of anti-cancer therapeutics are classified as tyrosine kinase inhibitors (for a
review see Levitski and Mishani, 2006, which is incorporated herein by reference in its
entirety). Tyrosine kinases include a number of cell surface receptors such as the VEGF
receptors. VEGF is one of the key regulators for both physiological and pathological
20 angiogenesis- Because of the multitude of cellular responses that are initiated and regulated
by VEGF^ and because of its specificity for the vascular endothelium, VEGF takes an
exceptional position among other growth factors (Petrova et ah Exp Cell Res, 253:117-130,
1999).

There are three VEGF-receptors (VEGFRl, VEGFR2, and VEGFR3). VEGFRl is
25 mainly expressed in hematopoietic stem cells, macrophages and monocytes as well as in
vascular endothelium. VEGFR2 is more characteristic of the vascular and lymphatic
endothelium, whereas VEGFR3 is predominantly expressed in lymphatic endothelium (Cross
et al, 2003).

Since VEGFR2 is generally considered the most important transducer of VEGF-
30 dependent angiogenesis, this receptor represents a major target within the angiogenesis-

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related kinases. VEGFR2 inhibitors include^ but are not limited to abt-869, amg706,
AZD2171, bay57-9352, bay43-9006 (sorafenib), XL647, XL999, GW786034, bevaciziimab,
PKC412, AEE788, PTK787 (vatalanib), OSI-930, OSI-817, SU11248, AG-013736, ZK3-
4709, quinazoline ZD6474, pyrrolocarbazole CEP-7055 (orally active N,Ndimethylglycine
5 ester of CEP-5241), and CP-547632. VEGFR2 inhibitors are generally known or can be
identified using VEGFR2 kinase assays,

A. Second Agents

Sorafenib can be combined with other phaxnciacologically active compounds ("second
agents") in naethods and compositions of the invention. In a preferred embodiment, the

10 second agents are capable of reducing pulmonary artery pressure or vascular resistance,
inhibiting thrombosis or thromboembohsm, or ensuring compliance of patients. Examples of
the second agents include, but are not limited to, anticoagulants, diuretics^, cardiac glycosides,
calcium channel blockers, vasodilators, prostacyclin and prostacyclin analogues, endothelin
receptor antagonists, phosphodiesterase inhibitors {e.g.^, PDE 5 inhibitors), endopeptidase

15 inhibitors, lipid lowering agents, thromboxane inhibitors, and other therapeutics known to
reduce pulmonary artery pressure.

Specific second agents are anticoagulants, which are useful in the treatment of
patients with PH who have an increased risk of thrombosis and thromboembolism. A
particular anticoagulant is warfarin (Coumadin®).

20 Other second agents include diuretics, cardiac glycosides, and oxygen. Digoxin

therapy is used to improve right ventricular function in patients with right ventricular failure.
Diuretics can be used to manage peripheral edema. Oxygen supplementation may be used in
those patients with resting or exercise-induced hypoxemia.

Calcium channel blockers such as diltiazem, amlodipine, and nifedipine can also be
25 used as second agents, particularly for vasoreactive patients at right heart catheterization.
These drugs are thought to act on the vascular smooth muscle to dilate the puhnonaiy
resistance vessels and lower the pulmonary artery pressure (Tapson, 2002).

Other second agents include vasodilators, particularly for NYHA/WHO class III and
rv patients with right heart failure who do not respond to calcixim channel blockers or are
30 unable to tolerate them. Examples of vasodilators include, but are not limited to, prostacyclin

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(e.g., prostaglandin I2 (PGI2), epoprostenol (EPO, Flolan®), treprostinil (RemodulinCE))), and
nitric oxide (NO).

Still other second agents are endothelin antagonists. One example is bosentan
(Tracleer®), which competitively binds to endothelin-1 (ET-1) receptors A + B, causing
5 reduction in pulmonary artery pressure.

Specific second agents used in the invention include;, but are not limited to,
amlodipine, nifedipine, diltiazem, bosentaa (Tracleer®), prostacyclin {e,g., epoprostenol
(Flolan®), treprostinil (Remodulin®), iloprost), warfarin (Coumadin®), tadalafil (Cialis®),
simvastatin (Zocor®), omapatrilat (Vanlev®), irbesartan (Avapro®), pravastatin
10 (Pravachol®), digoxin, nitric oxide, L-arginine, iloprost, betaprost, and sildenafil (Viagra®).

IV. METHODS OF TREATMENT AND MANAGEMENT

A. Diagnosis

Pulmonary Hypertension is typically defined as a pulmonary artery mean pressure
greater than 20 mm Hg with a pixlmonary vascular resistance greater than two Wood units.

15 Pulmonary hypertension is indicated by increased shortness of breath during exertion
accompanied by one of the known causes of PH. Methods of diagnosing PH include
echocardiography, Doppler flow studies, assessment of blood oxygenation, pulomonary
function, computer tomography of the chest, ventilation-perfusion lung scanning, and cardiac
catheterization (Nauser and Stites, 2001), Pulmonary hypertension left untreated results in

20 right ventricular failure and death. Diagnosis of PH may be associated with identification of
right ventricular hypertrophy on an ECG or prominent pulmonary arteries on a chest
radiograph. Once an indication of PH has been establish a patient will typically undergo two-
dimensional echocardiography with Doppler flow studies. Typically:, PH is confirmed by
identification of tricuspid regurgitation with right ventricular enlargement and/or dysfunction.

25 Once a patient has been diagnosed with PH, the patient should undergo testing to

identify any underlying causes for PH. The test include^ but are not limited to blood analysis,
including blood count, prothrombin time, partial thromboplastin time, hepatic profile,
autoimmune panel, basic naturetic peptide (BNP)^ and HIV testing; blood gas analysis;
pulmonary ftmction testing; CT scan; ventilation-perfiasion lung scan; cardiac catheterization;

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or combinations thereof (see Nauser and Stites, 2001 figure 3 algoritlun for evaluation of a
patient with suspected pubnonary hypertension).

The familial and medical history of a patient may be used to identify a subject at risk
of developing PH and is a candidate for prophylactic or preventative treatments.

5 B, Treatment

Treatment of PH depends on the stage and the mechanism of the disease. Typical
treatments for PH include, but are not limited to correction of underlj/ing cause (e.g.^ surgical
treatment of mitral stenosis^ left to right shunt, or accessible chronic thromboemboli;
afterload reduction, digoxin and diuretics for left ventricular dysfunction; prevention and

10 treatment of respiratory infection; avoidance of anorectic agents); decrease pulmonary
vasular resistance (e,g,^ vasodilation (oxygen, calcium channel blockers, prostacyclins, nitric
oxide), or anticoagulation); increase cardiac output (short-term parenteral inotropes or
digoxin); reduce volume overload (low-salt diet or diuretics); or surgery (lung transplant or
atrial septosotomy) (see Nauser and Stites, 2001 table 5 possible treatments for pulmonary

15 hypertension).

Several studies suggest that survival is increased when the patient is treated with
anticoagulant therapy, regardless of histopathologic subtype of PAH (Rubin et al, 1997).
Warfarin is used to maintain an International Normalized Ratio of 1.5- to 2-times the control
value, provided no contraindication to anticoagulation is present (Tapson, 2002). Warfarin is
20 the standard of care for thromboembolic PH.

Digoxin is used to prevent and treat supraventricular arrhythmias associated with
PAH and for patients who have concomitant left heart failure. However, no randomized
controlled clinical study has been performed to validate this strategy for patients with IP AH
(Tapson, 2002). Diuretics are reportedly useful in reducing excessive preload in patients with
25 right heart failure (Rubin et al, 1997). Oxygen supplementation is nsed in those patients
with resting or exercise-induced hypoxemia (Rubin et al., 1997; Tap son, 2002).

Arterial septostomy or lung transplant is indicated for patients who do not respond to
medical therapy (The Merck Manual 1999; Rubin, 2002). Arterial septostomy is intended to
serve as a bridge to transplantation.

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Medications presently used for the treatment of PH include calcium channel blockers
and pulmonary vasodilators (The Merck Manual 1999; Tapson, 2002). Calcium channel
blockers are utilized for "true responders" as evidenced by response during right heart
catheterization (McLaughlin et al^ 2004, which is incorporated herein by reference in its
entirety). Vasodilators include, but are not limited to epoprostenol, treprostinil, and iloprost.
Endothelin antagonists include, but are not limited to Tracleer and the like.
Phosphodiesterase inhibitors include, but are not limited to sildanefil and the like.

Metliods of this invention encompass methods of preventing, treating and/or
managing various types of PH, particularly PAH. As used herein, imless otherwise specified,
the term "preventing" or "prophylaxis" includes, but is not limited to, inhibiting or averting
one or more symptoms associated with PH. Symptoms associated with PH include, but are
not limited to, dyspnea, fatigue, weakness, chest pain, recurrent syncope, seizures, light-
headedness, leg edema, and palpitations. As used herein, unless otherwise specified, the term
"treating" refers to the administration of a composition after the onset of symptoms of PH,
whereas "preventing" refers to the administration prior to the onset of symptoms, particularly
to patients at risk of PH. As used herein and unless otherwise indicated, the term "managing"
encompasses preventing the recurrence of PH in a patient who had suffered from PH, and/or
lengthening the time that a patient who had suffered from PH remains in remission.

The invention encompasses methods of treating or managing patients who have been
previously treated for PH, as well as those who have not previously been treated for PH.
Because patients with PH have heterogenous clinical manifestations and varying cUnical
outcomes, it is preferred that patients should be treated according to the severity and stage of
the disease. Methods and compositions of this invention can be used in various stages or
types of PH including, but not limited to, primary PH, secondary PH and WHO classes I to
IV patients.

Methods encompassed by this invention comprise administering sorafenib, or a
pharmaceutically acceptable salt or prodrug thereof to a patient {e.g., a human) suffering, or
likely to suffer, firom PH. La one aspect of the invention, sorafenib is administered in single
or divided daily doses in an amoimt of from about 0.1 to about 1000 mg/day, from about 100
to about 800 mg/day, or from about 50 to about 400 mg/day.

C. Combination Therapy

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Administration of sorafenib and a second agent to a patient can occur simultaneously
or sequentially by tlie same or different routes of administration. The suitability of a
particular route of administration employed for a particular agent will depend on the agent
itself (e,g.^ whether it can be administered orally without decomposing prior to entering the
5 blood stream) and the disease being treated. A preferred route of administration for sorafenib
is oraL Another preferred route of administration for sorafenib is parenteral^ particularly for
patients who are in a peri-transplant period or in an end stage of PH. Preferred routes of
administration for the second agent of the invention are known to those of ordinary skill in
the art such as in Physicians' Desk Reference (2003).

10 Various combinations may be employed^, sorafenib is "A" and a second agent is "B":

A/B/A B/A/B B/B/A A/A/B A/B/B B/A/A A/B/B/B B/A/B/B

B/B/B/A B/B/A/B A/A/B/B A/B/A/B A/B/B/A B/B/A/A

B/A/B/A B/A/A/B A/A/A/B B/A/A/A A/B/A/A A/A/B/A

Administration of the compositions of the present invention to a patient will follow
1 5 general protocols for the administration of agents for the treatment of PAH. It is expected
that the treatment cycles would be repeated as necessary. It also is contemplated that various
standard therapies, as well as surgical intervention, may be applied in combination with the
described compositions and formulations.

The specific amount of the second agent will depend on the specific agent used, the
20 type of PH being treated or managed, the severity and stage of PH, and the amount(s) of
sorafenib and any optional additional agents concurrently administered to the patient. In
specific embodiments of the invention, the second agent is amlodipine, diltiazem, nifedipine,
prostacyclins (e.g-., epoprostenol (Flolan®), treprostinil (Remodulin®), iloprost), bosentan
(Tracleer®), warfarin (Coumadin®), tadalafil (Cialis®), simvastatin (Zocor®), omapatrilat
25 (Vanlev®), irbesartan (Avapro®), pravastatin (Pravachol®), digoxin, nitric oxide, L-arginine,
beraprost, or sildenafil (Viagra®).

In one embodiment of the invention, sorafenib is administered to reduce a period of
treatment with a second agent typically used to treat PH. In a particular embodiment, at the
beginning of week one, firom about 100 to about 800 mg/day of sorafenib is administered

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along with a second agent in an amount that those of ordinary skill in the art can deteimine by
their professional judgment- At the beginning of weeks 5, 9, 13, and 17^ withdrawal of the
second agent may occur in increments of 25% of the initial dose of the second agent. At the
beginning of week 17, dose of the second agent may be 800 mg/day if symptoms of a patient
5 do not worsen. If symptoms of a patient worsen, dose of the second agent may be increased
to stabilize the patient.

D. Combination with Surgery or Transplantation

This invention encompasses a method of treating or managing PH, which comprises
administering sorafenib, or a pharmaceutically acceptable salt or prodmg thereof, in
10 conjimction with surgery or transplantation therapy. As discussed herein, the treatment of PH
varies, depending on the stage and mechanism of the disease. Arterial septostomy or lung
transplantation may be necessary for PH patients who have failed to respond to other therapy.
Sorafenib may provide additive or synergistic effects when given before, concurrently with,
or after surgery or transplantation therapy in patients with PH.

15 V. PHARMACEUTICALS AND METHODS FOR THE TREATMENT OF

DISEASE

hi additional embodiments, the present invention concerns formulation of sorafenib
compositions disclosed herein in pharmaceutically-acceptable solutions for administration to
a cell, tissue, animal, or patient either alone, or in combination with one or more second agent
20 or second therapy.

Aqueous pharmaceutical compositions of the present invention will have an effective
amount of a sorafenib that modulates PH and/or its related pathologies or etiologies. Such
compositions generally will be dissolved or dispersed in a pharmaceutically acceptable
carrier or aqueous medium. An "effective amount,'^ for the purposes of therapy, is dejSned at
25 that amount that causes a clinically measurable difference in the condition of the subject.
This amount will vary depending on the substance, the condition of the patient, the type of
treatment, etc.

The phrases "pharmaceutically" or "pharmacologically acceptable" refer to molecular
entities and compositions that do not produce a significant adverse, allergic or other untoward
30 reaction when administered to an aaimal, or human, as appropriate. As used herein.

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"pharmaceutically acceptable carrier" includes aiay aaid all solvents, dispersion media^
coatings, antibacterial and antifimgal agents, isotonic and absorption delaying agents and the
like. The use of such media and agents for pharmaceutically active substances is well known
in the art. Except insofar as any conventional media or agent is incompatible with the active
5 ingredients, its use in the therapeutic compositions is contemplated. Supplementary active
ingredients^ such as other anti-diabetic agents, can also be incorporated into the compositions.

In addition to the compounds formulated for parenteral administration, such as those
for intravenous or intramuscular injection^ other pharmaceutically acceptable forms include^
e.g., tablets or other solids for oral administration; time release capsules; and any other form
1 0 currently used, including creams^ lotions, inhalants and the like.

The active compounds of the present invention will often be formulated for parenteral
administration, formulated for injection via the intravenous, intramuscular,

subcutaneous, or even intraperitoneal routes. The preparation of a composition that contains
sorafenib alone or in combination with a second therapeutic agent as active ingredients will
15 be known to those of skill in the art in light of the present disclosure. Typically, such
compositions can be prepared as injectables^ either as liquid solutions or suspensions; solid
forms suitable for using to prepare solutions or suspensions upon the addition of a liquid prior
to injection can also be prepared; and the preparations can also be emulsified.

Solutions of the active compounds as free base or pharmacologically acceptable salts
20 can be prepared in water suitably mixed with a surfactant, such as hydroxypropylcellulose.
Dispersions can also be prepared in glycerol, liquid polyethylene glycols, and mixtures
thereof and in oils. Under ordinary conditions of storage and use, these preparations contain
a preservative to prevent the growth of microorganisms.

The pharmaceutical forms suitable for injectable use include sterile aqueous solutions
25 or dispersions; formulations including sesame oil, peanut oil or aqueous propylene glycol;
and sterile powders for the extemporaneous preparation of sterile injectable solutions or
dispersions, hi many cases, the form must be sterile and must be fluid to the extent that easy
syringability exists. It must be stable under the conditions of manufacture and storage and
must be preserved against the contaminating action of microorganisms, such as bacteria and
30 fungi.

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The active compounds may be fomiulated into a composition in a neutral or salt form.
Pharmaceutically acceptable salts include the acid addition salts and which are formed with
inorganic acids such as, for example, hydrochloric or phosphoric acids, or such organic acids
as acetic, oxalic, tartaric, mandelic, and the like. Salts formed can also be derived from
5 inorganic bases such as, for example, sodium, potassium, ammonium, calcium^ or ferric
hydroxideS;, and such organic bases as isopropylamine, trimethylamine, histidine, procaine
and the like.

The carrier also can be a solvent or dispersion medium containing, for example,
water, ethanolj polyol (for example, glycerol, propylene glycol, and liquid polyethylene

10 glycol, and the like), suitable mixtures thereof, and vegetable oils. The proper fluidity can be
maintained, for example, by the use of a coating, such as lecithin, by the maintenance of the
required particle size in the case of dispersion and by the use of surfactants. The prevention
of the action of microorganisms can be brought about by various antibacterial and antifungal
agents, for example, parabens, chlorobutanol, phenol, sorbic acid, thimerosal, and the like. In

15 many cases, it will be preferable to include isotonic agents, for example, sugars or sodium
chloride. Prolonged absorption of the injectable compositions can be hrought about by the
use in the compositions of agents delaying absorption, for example, alrmiinum monostearate
and gelatin.

Sterile injectable solutions are prepared by incorporating the active compoimds in the
20 required amount in the appropriate solvent with various other ingredients enumerated above,
as required, followed by filtered sterilization. Generally, dispersions are prepared by
incorporating the various sterilized active ingredients into a sterile vehicle which contains the
basic dispersion medium and the required other ingredients from those enumerated above. In
the case of sterile powders for the preparation of sterile injectable solutions, the preferred
25 methods of preparation are vacuum-drying and fireeze-drying techniques which yield a
powder of the active ingredient plus any additional desired ingredient from a previously
sterile-filtered solution thereof.

Upon formulation, solutions will be administered in a manner compatible with the
dosage fomiulation and in such amount as is therapeutically effective. The formulations are
30 easily administered in a variety of dosage forms, such as the type of injectable solutions
described above, with even drug release capsules and the like being employable.

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For parenteral administration in an aqueous solution, for example, the solution should
be suitably buffered if necessary and the liquid diluent first rendered isotonic with sufficient
saline or glucose. These particular aqueous solutions are especially suitable for intravenous,
intramusculaiv subcutaneous and intraperitoneal administration. In this connection, sterile
aqueous media which can, be employed will be known to those of skill in the art in light of the
present disclosure. For example, one dosage could be dissolved in 1 mL of isotonic NaCl
solution and either added to 1000 mL of hypodermoclysis fluid or injected at the proposed
site of infusion, (see for example, "Remington's Pharmaceutical Sciences" 1035-1038 and
1570-1580). Some variation in dosage will necessarily occur depending on the condition of
the subject being treated. The person responsible for administration will, in any events
determine the appropriate dose for the individual subject.

In certain aspects of the methods of the invention, the route that the therapeutic
composition is administered may be by parenteral administration. The parenteral
administration maybe intravenous injection, subcutaneous injection, intramuscular injection,
ingestion or a combination thereof In certain aspects, the composition comprising sorafenib
is administered from about 0,1 to about 10 micro gram/kg/body weight per dose. In certain
aspects, the composition comprising sorafenib is administered from about 1 to about 5
microgram/kg/body weight per dose. In certain aspects, the composition comprising
sorafenib is administered from about 1.2 to about 2.4 microgram/kg/body weight per dose. In
certain aspects, the amount of sorafenib administered per dose may be about 0.1, about 0.2,
about 0.3, about 0.4, about 0.5, about 0,6, about 0.7, about 0,8, about 0.9, about LO, about

1.1, about 1.2, about 1.3, about 1. 4, about 1.5, about L6, about 1.7, about 1.8, about 1.9,
about 2.0, about 2,1, about 2.2, about 2.3, about 2.4, about 2.5, about 2.6, about 2. 7, about

2.8, about 2.9. about 3.0, about 3.1, about 3.2, about 3.3, about 3.4, about 3 5, about 3.6,
about 3.7, about 3.8, about 3.9, about 4,0, about 4.1, about 4.2, about 4.3, about 4.4, about

4.5, about 4,6, about 4. 7, about 4.8, about 4.9, about 5.0, about 5.1, about 5.2, about 5.3,
about 5.4, about 5.5, about 5.6, about 5.7, about 5.8, about 5.9, about 6. 0, about 6.1, about

6.2, about 6.3, about 6.4, about 6.5, about 6.6, about 6.7, about 6.8, about 6.9, about 7.0,
about 7.1, about 7.2, about 7. 3, about 7.4, about 7.5, about 7.6, about 7.7, about 7.8, about

7.9, about 8.0, about 8.1, about 8.2, about 8,3, about 8.4, about 8.5, about 8. 6, about 8.7,
about 8.8, about 8.9, about 9.0, about 9.1, about 9.2, about 9.3, about 9.4, about 9.5, about

9.6, about 9.7, about 9.8. about 9.9 to about 10.0 or more nanogram/kg/body,
microgram/kg/body, or milligram/kg/body.

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Formulation of phannaceutically-acceptable excipients and carrier solutions is well-
Icnown to those of skill in the art, as is the development of suitable dosing and treatment
regimens for using the particular compositions described herein in a variety of treatment
regimens^ including e.g.^ oral^ parenteral, intravenous, intranasal, and intramuscular
5 administration and formulation.

A- Alimentary Delivery

The tenn "alimentary delivery" refers to the administration, directly or otherwise, to a
portion of the alimentary canal of a subject or patient. The term "alimentary canal" refers to
the tubular passage that functions in the digestion and absorption of food and the elimination
of food residue, which runs from the mouth to the anus, and any and all of its portions or
segment Ss e,g.^ the oral cavity, the esophagus, the stomach, the small and large intestines and
the colon, as well as compound portions thereof such as, e.g., the gastro-intestinal tract.
Thus, the term "alimentary delivery" encompasses several routes of administration including,
but not limited to, oral, rectal, endoscopic and sublingual/buccal administration. A common
requirement for these modes of administration is absorption over some portion or all of the
alimentary tract and a need for efficient mucosal penetration of the agent so administered.

1, Oral Delivery

In certain applications, the pharmaceutical compositions disclosed herein may be
delivered via oral administration to an animal. As such, these compositions may be
20 formulated with an inert diluent or with an assimilable edible carrier, or they may be enclosed
in hard- or soft- shell gelatin capsule, or they may be compressed into tablets, or they may be
incorporated directly with the food of the diet.

The active compoimds may even be incorporated with excipients and used in the form
of ingestible tablets, buccal tables, troches, capsules, elixirs, suspensions, syrups, wafers, and

25 the like (Mathiowitz et al, 1997; Hwang et ah, 1998; U.S. Patents 5,641,515; 5,580,579 and
5,792,451, each specifically incorporated herein by reference in its entirety). The tablets,
troches, pills, capsules and the like may also contain the following: a binder, as gum
tragacanth, acacia, cornstarch, or gelatin; excipients, such as dicalcium phosphate; a
disintegrating agent, such as com starch, potato starch, alginic acid and the like; a lubricant,

30 such as magnesium stearate; and a sweetening agent, such as sucrose, lactose or saccharin
may be added or a flavoring agent, such as peppermint, oil of wintergreen, or cherry

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flavoring. When the dosage unit form is a capsule, it may contain, in addition to materials of
the above type, a liquid carrier. Various other materials may be present as coatings or to
otherwise modify the physical form of the dosage imit. For instance, tablets, pills^ or
capsules may be coated with shellac^ sugar, or both. A syrup or elixir may contain the active
5 compound sucrose as a sweetening agent methyl and propylparabens as preservatives, a dye
and flavoring, such as cherry or orange flavor. Of course, any material used in preparing any
dosage unit form should be pharmaceutically pure and substantially non-toxic in the amounts
employed. In addition, the active compoimds may be incorporated into sustained-release
preparation and formulations.

10 Typically, these formulations may contain at least about 0.1% of the active compound

or more, although the percentage of the active ingredient(s) may, of course, be varied and
may conveniently be between about 1 or 2% and about 60% or 70% or more of the weight or
volume of the total formulation. Naturally, the amormt of active compound(s) in each
therapeutically useful composition may be prepared is such a way that a suitable dosage will

15 be obtained in any given unit dose of the compound. Factors such as solubility,
bioavailability-, biological half-life, route of administration, product shelf life, as well as other
pharmacological considerations will be contemplated by one skilled in the art of preparing
such pharmaceutical formulations, and as such, a variety of dosages and treatment regimens
may be desirable.

20 2. Endoscopic Administration

Endoscopy can be used for therapeutic delivery directly to an interior portion of the
alimentary tract. For example, endoscopic retrograde cystopancreatography (ERCP) takes
advantage of extended gastroscopy and permits selective access to the biliary tract and the
pancreatic duct (Hirahata et al.^ 1992). However, the procedure is unpleasant for the patient,
25 and requires a highly skilled staff.

3. Rectal Administration

Therapeutics administered by the oral route can often be alternatively administered by
the lower enteral route, t e. , through the anal portal into the rectum or lower intestine. Rectal
suppositories, retention enemas or rectal catheters can be used for this pmpose and may be
30 preferred when patient compliance might a otherwise be difficult to achieve {e.g,^ in pediatric
and geriatric applications, or when the patient is vomiting or unconscious). Rectal

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administration may result in more prompt and higher blood levels than the oral route, but the
converse may be true as well (Remington's Pharmaceutical Sciences, 711, 1990). Because
about 50% of the tlierapeutic that is absorbed from the rectum will bypass the liver,
administration by this route significantly reduces the potential for first-pass metabolism
5 (Ben&tet al., 1996).

B. In j ectable Delivery

In certain circumstances it will be desirable to deliver the pharmaceutical
compositions disclosed herein parenterally, intravenously, intramuscularly, or even
intraperitoneally as described in U.S. Patents 5,543,158; 5,641,515 and 5,399,363 (each

10 specifically incorporated herein by reference in its entirety). Solutions of the active
compounds as free base or pharmacologically acceptable salts may be prepared in water
suitably mixed with a surfactant, such as hydroxypropylcellulose. Dispersions may also be
prepared in glycerol, liquid polyethylene glycols, and mixtures thereof and in oils. Under
ordinary conditions of storage and use, these preparations contain a preservative to prevent

15 the growth of microorganisms.

The pharmaceutical forms suitable for injectable use include sterile aqueous solutions
or dispersions and sterile powders for the extemporaneous preparation of sterile injectable
solutions or dispersions (U.S. Patent 5,466,468, specifically incorporated herein by reference
in its entirety). In all cases the form must be sterile and must be fluid to the extent that it is
20 easy to use a syringe.

25 Pharmaceixtical Sciences, 1035-1038 and 1570-1580. Some variation in dosage will
necessarily occur depending on the condition of the subject being treated. The person
responsible for administration will, in any event, determine the appropriate dose for the
individual subject. Moreover, for himian administration, preparations should meet sterility,
pyrogenicity, and the general safety and purity standards as required by FDA Office of

30 Biologies standards.

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4. Parenteral Delivery

The term "parenteral delivery" refers to the administration of a therapeutic of the
invention to an animal in a manner other than through the digestive canal. Means of
preparing and administering parenteral pharmaceutical compositions are loiown in the art
5 (see, e.g.. Remington's Pharmaceutical Sciences, pages 1545-1569, 1990).

5. Intraluminal administration

Intraluminal administration, for the direct delivery of a therapeutic to an isolated
portion of a tubular organ or tissue {e,g.y such as an artery, vein, ureter or urethra), may be
desired for the treatment of patients with diseases or conditions afflicting the lirnien of such

1 0 organs or tissues. To effect this mode of administration, a catheter or cannula is surgically
introduced by appropriate means. After isolation of a portion of the tubular organ or tissue
for which treatment is sought, a composition comprising a therapeutic of the invention is
infused through the cannula or catheter into the isolated segment. After incubation for fi-om
about 1 to about 120 minutes, during which the therapeutic is taken up or in contact with the

15 cells of the interior lumen of the vessel, the infusion cannula or catheter is removed and flow
within the tubular organ or tissue is restored by removal of the ligatures which effected the
isolation of a segment thereof (Morishita et al^ 1993). Therapeutic compositions of the
invention may also be combined with a biocompatible matrix, such as a hydrogel material,
and applied directly to vascular tissue in vivo.

20 C. Nasal Delivery

In certain embodiments, the pharmaceutical compositions may be delivered by
intranasal sprays, inhalation, and/or other aerosol delivery vehicles. Methods for delivering
genes, nucleic acids, and peptide compositions directly to the lungs via nasal aerosol sprays
has been described e.g.^ in U.S. Patents 5,756,353 and 5,804,212 (each specifically

25 incorporated herein by reference in its entirety). Likewise, the delivery of dmgs using
intranasal microparticle resins (Takenaga et ah, 1998) and lysophosphatidyl-glycerol
compounds (U.S, Patent 5,725,871, specifically incorporated herein by reference in its
entirety) axe also well-known in the pharmaceutical arts. Likewise, transmucosal drug
delivery in the form of a polytetrafluoroetheylene support matrix is described in U.S. Patent

30 5,780,045 (specifically incorporated herein by reference in its entirety).

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D. Epidermal and Transdermal Delivery

Epidermal and Transdermal Delivery, in which pharmaceutical compositions
containing therapeutics are applied topically, can be used to administer drugs to be absorbed
by the local dermis or for further penetration and absorption by underlying tissues,
5 respectively. Means of preparing and administering medications topically are known in the
art (see^ e.g.^ Remington's Pharmaceutical Sciences, 1596-1609;, 1990).

E. Liposome-, Nanocapsule-, and Microparticle-Mediated Delivery

In certain embodiments, the inventors contemplate the use of liposomes,
nanocapsules, microparticles, microspheres, lipid particles, vesicles, and the like, for the
10 introduction of the compositions of the present invention into suitable host cells. la
particular, the compositions of the present invention may be formulated for delivery either
encapsulated in a lipid particle, a liposome, a vesicle^ a nanosphere, or a nanoparticle or the
like.

Such formulations may be preferred for the introduction of pharmaceutically-
15 acceptable formulations of the nucleic acids or constmcts disclosed herein. The formation
and use of liposomes is generally known to those of skill in the art (see for example,
Couvreur et aL, 1977; Couvreur, 1988; Lasic, 1998; which describes the use of liposomes and
nanocapsules in the targeted antibiotic therapy for intracellular bacterial infections and
diseases). Recently^ liposomes were developed with improved serum stability and circulation
20 half-times (Gabizon and Papahadjoponlos, 1988; Allen and Chorua, 1987; U.S, Patent
5,741^516, specifically incorporated herein by reference in its entirety). Further^ various
methods of liposome and liposome like preparations as potential drug carriers have been
reviewed (Takakura, 1998; Chandran et ah, 1997; Margalit, 1995; U.S. Patent 5,567,434;
5,552,157; 5,565,213; 5,738,868 and 5, 795,587, each specifically incorporated herein by
25 reference in its entirety).

Liposomes are formed firom phospholipids that are dispersed in an aqueous medium
and spontaneously form multilamellar concentric bilayer vesicles (also termed multilamellar
vesicles (MLVs). MLVs generally have diameters of firom 25 nm to 4 |Lim. Sonication of
MLVs results in the formation of small imilamellar vesicles (SUVs) with diameters in the
30 range of 200 to 500 A, containing an aqueous solution in the core.

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The fate and disposition of intravenously injected liposomes depend on their physical
properties, such as size, fluidity, and surface charge. They may persist in tissues for h or
days, depending on their composition, and half Uves in the blood range firom min to several h.
Larger liposomes, such as MLVs and LUVs, are taken up rapidly by phagocytic cells of the
5 reticuloendothelial system, but physiology of the circulatory system restrains the exit of such
large species at most sites. They can exit only in places where large openings or pores exist
in the capillary endothelium, such as the sinusoids of the liver or spleen. Thus, these organs
are the predominate site of uptake. On the other hand^ SUVs show a broader tissue
distribution but still are sequestered highly in the liver and spleen. In general, this in vivo
10 behavior limits the potential targeting of liposomes to only those organs and tissues
accessible to their large size. These include the blood, liver, spleen, bone marrow, and
lymphoid organs.

Alternatively, the invention provides for pharmaceutically-acceptable nanocapsule
formulations of the compositions of the present invention. Nanocapsules can generally

15 entrap compounds in a stable and reproducible way (Henry-Michelland et aL^ 1987;
Quintanar-Guerrero et al.^ 1998; Douglas et aL, 1987). To avoid side effects due to
intracellular polymeric overloading, such ultrafine particles (sized around 0.1 [mgr]m) should
be designed using polymers able to be degraded in vivo. Biodegradable polyalkyl-
cyanoacrylate nanoparticles that meet these requirements are contemplated for use in the

20 present invention. Such particles may be are easily made, as described (Couvreur et ah^ 1980;
1988; zur Muhlen et aL, 1998; Zambaux et al, 1998; Pinto-Alphandary et al. , 1995 and U.S.
Patent 5,145,684, specifically incorporated herein by reference in its entirety).

VI. KITS

In some cases, agents of the invention are not administered to a patient at the same
25 time or by the same route of administration. This invention therefore encompasses kits
which, when used by the medical practitioner, can simplify the administration of appropriate
amounts of agents to a patient,

A typical kit or composition of the invention comprises a dosage form of sorafenib, or
a pharmaceutically acceptable salt or prodrug thereof. Klits encompassed by this invention
30 can further comprise additional active agents such as amlodipine, dilitazem, nifedipine,
adenosine, epoprostenol (Flolan®), treprostinil (Remodulin®), bosentan (Tracleer®),

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warfarin (Coumadin®), tadalafil (Cialis®), simvastatin (Zocor®), omapatrilat (Vanlev®),
irbesartan (Avapro®), pravastatin (Pravachol®), digoxin, nitric oxide, L-arginine, iloprost,
beraprost, and sildenafil (Viagra®), or a combination thereof. Examples of the additional
active agents include, but are not limited to, those disclosed herein.

5 Kits of the invention can further comprise devices that are used to administer the

active agents. Examples of such devices include, but are not limited to, syringes, drip bags,
patches, and inhalers.

Elits of the invention can farther comprise pharmaceutically acceptable vehicles that
can be used to administer one or more active agents. For example, if an active agent is

10 provided in a solid form that must be reconstituted for parenteral administration, the kit can
comprise a sealed container of a suitable vehicle in which the active agent can be dissolved to
form a particulate-free sterile solution that is suitable for parenteral administration. Examples
of pharmaceutically acceptable vehicles include, but are not limited to: Water for Injection
USP; aqueous vehicles such as, but not limited to. Sodium Chloride Injection, Ringer's

15 Injection, Dextrose Injection, Dextrose and Sodium Chloride Injection, and Lactated Ringer*s
Injection; water-miscible vehicles such as, but not limited to, ethyl alcohol, polyethylene
glycol, and polypropylene glycol; and non-aqueous vehicles such as, but not limited to, com
oilj cottonseed oil, peanut oil, sesame oil, ethyl oleate, isopropyl myristate, and benzyl
benzoate.

20 EXAMPLES

The following examples are included to demonstrate embodiments of the invention.
It should be appreciated by those of skill in the art that the techniques disclosed in the
examples which follow represent techniques discovered by the inventor to function well in
the practice of the invention, and thus can be considered to constitute preferred modes for its
25 practice. However, those of skill in the art should, in light of the present disclosure,
appreciate that many changes can be made in the specific embodiments which are disclosed
and still obtain a like or similar result without departing from the spirit and scope of the
invention.

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EXAMPLE 1

Pulmonary Hypertension Connection Database/Pulmonary Hypertension Specimen

Collection

The Pulmonary Hypertension Connection (PHC) has collected baseline demographic,
5 clinical phenotype, medication^ echocardiography, exercise test, and cardiac catheterization
data for 900 patients followed by the inventors practice since its inception in 1980-
Development of this database began at Rush and has continued at the University of Chicago,
Currently established at the University of Chicago^, the Pulmonary Hypertension Program has
over 1200 active patients. Since receiving IRB-approval over 1,000 active patients have
10 provided informed consent and a fiill-time data manager continues to input data on past and
active patients. The PHC stores clinical data but also provides statistical analysis software in
the single unit for rapid analysis by a trained investigator.

In January 2005, the inventors' protocol to generate a longitudinal specimen
collection entitled, "Biomarkers hi Pulmonary Hypertension" received IRB approval. The

15 protocol is for collection of DNA, peripheral blood specimens, and clinically indicated
central blood specimens. Discovery of relevant biomarkers in these specimens can be
immediately and safely integrated into a prospective study and routine clinical care. Patients
evaluated by pulmonary hypertension specialists who consent to the collection and archiving
of plasma, serum, and DNA are currently enrolled. Blood is collected during clinically

20 indicated evaluations either from a peripheral vein at scheduled office visits or from central
catheters placed during cardiac catheterization. Plasma, serum, and DNA are isolated, frozen
and stored by standard techniques in accord with International Society for Biological and
Environmental Repositories (ISGER) best practices (Somiari et al.^ 2004; Friede et aL^ 2003).
Coding of these specimens allows for retrospective selection of appropriate specimens to test

25 potential biomarkers for prediction/association with specific clinical phenotypes identified in
the PHC.

EXAMPLE 2

Development of Novel Endpoints

The clinical assessment of patients with pulmonary hypertension currently involves an
30 assessment of exercise capacity, echocardiography, and cardiac hemodynamics. Overall
assessment is based on a combination of these factors but there have not been any guidelines

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on treatment based on the overall assessment, only based on worsening functional class and
cardiac hemodynamics. Invasive hemodynamics is still the most reliable and most accurate
assessment of pulmonary vascular resistance. Catheterization does not provide information
on the patient's functional ability, right ventricular or pulmonary vascular reserve^ or on
5 pathologic vascular remodeling of the pulmonary circulation (regression, identification of
plexiform lesions). Alternative non-invasive techniques may prove to be better biomarkers
for PAH. The following experimental endpoints will be evaluated as novel measures of
disease activity: Naughton-Balke treadmill test (TT), 3DE, and 64 slice CT scan.

Naiighton-Balke Treadmill Test (TT) - 6MW is preformed by the subject walking
10 on a flat surface at his/her own pace. The 6MW is not a true measure of exercise from a
physiology perspective. Cardiopulmonary exercise testing in few centers is a better correlate
of exercise physiology and hemodynamics, (Oudiz et al.^ 2006; Yasunobu et ah, 2005) but
this test is time consuming, expensive, and difficult to do with reproducibiUty in
unexperienced centers. The University of Chicago center is gaining expertise in this non-
15 invasive test and may in the future incorporate this testing in protocols. The metabolic
equivalent, or MET, is the amount of oxygen used by a seated person and is a predictor of
survival in the general population. It is a physiologic measure of exercise capacity. The
Naughton-Balke exercise protocol, (Patterson et al.^ 1972) measured in METs is easy to
administer by programming a standard treadmill, is easily reproducible, inexpensive, and has
20 been preformed by programs at the University of Chicago for many years. Because of the
inventors familiarity with this test, and because it is a better measure of exercise physiology
than the 6MW, it is contemplated that the MET will be a better predictor and measure to
follow for PH patients.

Using data from the Intravenous Treprostinil, study I determined the reliability of
25 MET compared to the 6MW. Both tests were done by each patient in the study at multiple
time points. Pearson correlation coefficient (r) was calculated to express inter-relationship
between measures of exercise capacity. Intra-class correlation coefficient (ICC) was used to
indicate the repeated reliability of exercise capacity measures over time. 6MW and MET
were symmetrically distributed and correlated (r=0.63). ICCs for 6MW, TT, and MET were
30 0.77, 0.82, and 0.80, respectively. Fimctional class correlated with 6MW and MET at
baseline and at wk 12 (all p<0.01), but hemodynamics did not correlate with exercise
measures consistently. Based on this result, MET is as reliable and reproducible as the 6MW.

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The next step is to prove that MET is a better predictor aiid surrogate endpoint than the
6MW.

Three-Dimensional Echocardiography (3DE) - DE software (TomTec, Germany)
has been developed that semi-automatically detects RV endocardial borders and addresses
5 drawbacks of prior RV quantification. Patients have RT3DE as part of their routine
evaluation with two-dimensional echocardiography (2DE). Investigation of the influence of
different degrees of pulmonary hypertension on RV remodeling in patients and development
of novel indices that may better assess this phenomenon are under way. Using a matrix array
probe and Sonos 7500 (Philips, MA), a wide-angled acquisition of the RV during a breath
10 hold gated to ECG will be obtained. The RV volume will be analyzed using software that
semi-automatically detects RV endocardial borders resulting in global and regional RV
volume and ejection fraction (EF). Several RV indices will include RV diameter in 2D and
3D, 3D area measurements at the tricuspid valve (TV) annulus, 1/3 of the RV and 2/3 of the
RV.

15 In initial observations 3D echocardiographers at flie University of Chicago, found that

RV remodeling is most evident at 1/3 of the RV. The TV annulus does not significantly
dilate until patients have severe PH. The inventors anticipate that this technology will
expand the knowledge of how the RV reacts towairds changes in pressure^ volume overload or
different disease states. Patients will continue to have RT3DE in Phase I/II trials to assess

20 and monitor response to therapy.

Computed Tomography (CT) Scaus - At the University of Chicago under the
direction of a leading radiologist in computer based analysis of radiographic imaging; the
inventors have developed a fully automated lung segmentation method for thoracic CT scans
that has been used for automated analysis of lung parenchyma texture, including the lung

25 texture of patients with PH. A preliminary study of 28 CT scans (14 from PH patients and 14
from aged-matched "normal" patients) was conducted. The lung texture analysis method was
applied to a single section from each CT scan; these individual sections were manually
selected at the level of the bifurcation of the pulmonary artery. The lung texture features
were used to discriminate between the normal and the PH groups. This discrimination task

30 was performed by a linear discriminant classifier^ the performance of which was evaluated by
receiver operating characteristic (ROC) analysis with the LABROC4 program (C.E. Metz^
Ph.D, The University of Chicago). The automated method achieved an area under the ROC

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curve of 0.97 (out of a maximum 1.0) in this discrimination task (submitted ERS). Based on
this preliminary study^ all patients seen by our PH center are asked to enroll in the CT
database-a repository allowing high level analyses of scans. Shortly all PH patients with
clinical indications for a chest CT will have a 64 shoe CT to continue work on this project
5 and to detennine the ability to detect plexifomi lesions.

EXAMPLE 3

Preclinical Data with Dahl-Sensitive Rats

Human Pulmonary Hypertension (PH) is an often fatal vascular disorder affecting -2-
3 new cases/million/ yr characterized by increased pulmonary artery pressure, right heart

10 failure, and death. Current strategies to treat PH are problematic and do not address the
vascular remodeling (smooth muscle contraction, hypertrophy) characteristic of the disease.
PH exhibits signijBcant overlap with cancer pathophysiology with abnormalities in signal
transduction and cellular proliferation (endothelium, smooth muscle) resulting in an
angioproliferative vasculopathy. As cancer and pulmonary hypertension share the

15 involvement of angiogenesis and growth factor pathways, it was hypothesized that sorafenib
may represent a novel therapeutic agent for PAH. The inventors set out to conduct pre-
clinical studies to evaluate the safety and efficacy of sorafenib in a rodent model of hypoxia-
induced PAH. This rat model combines hypoxia and SU5416, a VEGFR-2 inhibitor, which
together produce PH characterized by: vasoconstriction, elevated pulmonary artery pressure,

20 right ventricular hypertrophy, and vascular remodeling. (Taraseviciene-Stewart et ah FASEB
J. 2001;15;427-.438). Another feature of this model is smooth muscle medial thickening and
endothelial cell apoptosis.

Protocol includes an initial administration of SU5416 subcutaneously at 20 mg/kg
followed daily by sorenfenib oral daily doses of 2.5 mg/kg. Some animals were exposed to

25 chronic hypoxia (10% O2)- The animals were divided into five experimental groups: hypoxia
"i- sorafenib; hypoxia + SU5416 + sorafenib^ normoxia + vehicle control; Hypoxia -t- vehicle;
and hypoxia 4- SU5416. PAP, RVSP, Echo, and DNA microarrays were used to measure
various physiological and molecular biological parameters. FIG. 4 illustrates that
hypoxia/SU5416-induces increases in right heart pressures and right heart hypertrophy

30 (RV/LV+Septum). FIG. 4 also illustrates that sorafenib prevented hypoxia s- SU5416
development of right heart hypertrophy (RV/LV+Septum) in Dahl SS rats. FIG, IB
illustrates that sorafenib prevents hypoxia + SU5416 induced pulmonary hypertension and

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remodeling. Sorafenib Prevents Remodeling in Dahl SS with PH (Health Edwards Grading)
H/E sections (FIG. 17).

To study potential mechanisms of sorafenib effects on PH RNA was isolated from rat
lung tissue and analyzed using the Rat Chip II (Affymetrix). Sorafenib attenuated
5 physiologic and histopathologic changes in PAH in a rodent model of PH. Mechanisms of
PAH pathobiology is poorly understood therefore^ to explore potential mechanistic pathways
the inventors conducted bioinformatic studies and expression profiling. Expression profiling
revealed at least 179 genes differentially regulated by sorafenib^ when comparing profiling
data to normoxia using GCRMA normalization in R and SAM (6 > 0.639, minimum fold

10 change > 1.7). The candidate genes identified fell into various gene ontology classes, for
example 4% were in the lung development and growth factors class (e.g., Bambi, Tgfl33:,
Ltbp2), 13% in the cell migration/ECM class (e.g., Itga3_predicted, Cspg4j Cxcll2, Reln^
CoUSal, Cthrcl^ Hmgcr^ Cnnl^ Col6a2, Jag2), 4% in the apoptosis class (e,g,, Anzal,
CoUSal, Jag2), 4% in the smooth muscle/fiber formation class (e.g,^ Des^ TpmS, Jph2)5 10%

15 in the cell proliferation class (e.g., Anxal, Timpl, Lamb_l predicted, Cspg4, Cxcll2, Gja4,
Jag2, Tgfb3), 6% in the blood vessel development class (e.g,, 0x0112, Cspg4, Gja4, CollSal,
Serpinel), and 5% in the angiogenesis class (Cxcll2, Cspg4, Coll Sal, Serpinel).

Table 2 Gene ontology for sorafenib influenced gene, genes known to be involved in PH,

PubMatrix Terms

Gene
Symbol

Gene Name

Pulmonarv
Hypertension

Vascular
Remodeling

Hypoxia

Endothelium

DBS

desmin

103

308

585

McptlO

Mast cell protease 10

Timpl

Tissue inhibitor of
metalloprotease 1

118

Fbnl

Fibrillin 1

Nuprl

Nuclear protein 1

104

140

1680

1646

Tgfb3

Transforming growth
factor beta 3

111

102

442

Bmprla

Bone morphogenetic
protein receptor, type
lA

Bmpr2

Bone morphogenetic
protein receptor, type n

121

Itga6

Integrin, alpha 6

364

Tipc6

Transient receptor
potential cation channel,
subfamily C member

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Table 3 Gene ontology for sorafenib influenced genes, unknown genes

UnkIlo^?m genes

PubMatrix Terms

Gene symbol

Gene name

Pulmonary
hypertension

Vascular
remodeling

Hypoxia

Endothelium

Ankrdl

Anlcyrin repeat domain 1

Cnnl

Calponinl

Chstl2

Carbolivdrate
sulfo transferase 12

T-Ttt! p*cr 1

3 -livdroxv-3 -
methylglutaryl-
coenzvme A synthase 1

Cvtochrome P450,
subfamily 5 1

Esml

EndotheHal cell-specific
molecule 1

Gja4

Gap junction membrane
channel protein alpha 4

Cxcll2

Chemokine (C-X-C
motif) ligand 12

149

Jam3

Junctional adhesion
molecule 3

Anxal

Annexin Al

Ltbp2

Latent transforming
growth factor beta
binding protein 2

Mgll

Macrophage galactose
N-acetyi-galactosamine
specific lectin 1

The inventors have successfully utilized sorafenib to attenuate (physiologic and
histopathologic) the development of rodent pulmonary hypertension model (Dahl SS)
5 utilizing chronic hypoxia and SU5416 administration. Gene expression profiling studies
identified genes which are well recognized to be involved in angiogenesis, endothelial cell
apoptosis, and PH (Table 2), as well as genes previously not associated with PH representing
potential novel candidate genes (Table 3). Given its safety in advanced cancer patients,
further studies exploring both the mechanism of action as well as human studieS;, evaluating
10 sorafenib safety and efficacy in PH should be pxirsued.

Preclinical data with Dahl-sensitive rats given sorefenib with hypoxia and SU5416
did not develop evidence of PAH. Sorafenib may have a beneficial effect in the treatment
PAH, The PHC database enables the phenotype our patients to be determined based on
clinical data, which will be a useful tool in discriminating response to therapy. Non-invasive
15 methods that may better evaluate and prove to be better screening and biomarkers in PAH
include exercise treadmill testing by a Naughton-Balke protocol, 3DE, and CT scanning.

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EXAMPLE 4
Clinical Studies

The pathophysiology of PAH overlaps the pathophysiology of cancer with aberrancies
in signal transduction leading to abnormal endothelial and smooth muscle cell interactions
5 and to angioproliferative vasculopathy. New signal transduction inhibitors being evaluated
for the treatment of cancer represent potential effective therapies for PAH. With an existing
phase I cancer therapeutics program, the University of Chicago provides a iinique
environment to improve PAH care. Having established that the recently FDA-approved
agent, sorafenib, an inhibitor of multiple kinases important to angiogenesis (Raf-1 kinase
10 inhibitor, VEGFR-2, VEGFR-3, PDGFR-g), protected rats from developing PAH in the
SU5416/hypoxia model of PAH, the inventors contemplate evaluation of this agent in Phase I
and Phase II trials,

A. Single center Phase IB trial of sorafenib in PAH patients.

Study Objectives Phase IB study: To determine the toler ability of oral daily sorafenib
15 in combination with prostacyclin sildenafil in pulmonary hypertension patients. This
design is a single-center^ Phase IB dose escalation study of sorafenib up to the known MTD
of 400 mg twice daily. Administration will continue until the occurrence of unacceptable
toxicity (described below)^ withdrawn consent, disease progression, hospitalization for
PH/iight heart failure, lung transplantation, or death.

20 Accrual: The PH program is currently following over 150 subjects on stable

prostacyclin therapy. Phase I will enroll 12 subjects and be completed within 6-9 months.

Rationale for Inclusion Criteria: Prostacyclin therapy is the most efjacacious therapy
ciorrently available for PAH. Long-term prostacyclin replacement is supported by the
pathophysiology of PAH, the relative lack of prostacyclin seen in PAH, and prostacyclin's
25 positive effects on pulmonary vascular bed. However, prostacyclin therapy is not curative.
As a class, the side effect profile of all prostacyclins is similar to that of epoprostenol and is
usually minimal and well tolerated in most subjects. These include flushing, headache,
nausea^ loose stool, jaw discomfort with "first bite", and foot pain with prolonged standing or
walking (Barst et ah, 1996; McLaughlin et ah, 2002; Sitbon et ah, 2002).

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Epoprostenol, the first approved tlierapy for PAH, has a half-life of no more than 1-2
minutes, mandating continuous intravenous therapy via a central catheter (Data et al.^ 1981).
Cohort analyses in Europe and in the United States have provided convincing evidence of its
long term benefits (McLaughlin et al^ 2002; Sitbon et al^ 2002). Because of its
phannacology, prostacyclin analogues were developed to ease administration. Treprostinil is
a tricyclic benzidene prostacyclin analogue that shares pharmacologic actions with
epoprostenol (Clapp et aL, 2002) Treprostinil differs firom epoprostenol in that it is
chemically stable at room temperature and neutral pH and has a longer half-life (3-4 hours)
(Wade et al., 2004), Subcutanous treprostinir was approved in 2002 for the treatment of New
York Heart Association (NYHA) class II-IV PAH patients (Simonneau et al, 2002) and
recently, the FDA approved the use of intravenous treprostinil based on bioequivalence to
subcutaneous therapy (Laliberte et al, 2004). Iloprost is a chemically stable prostacyclin
analog that can be delivered by inhaler/nebulizer (Hoeper et al, 2000). This allowed a
targeted approach, with direct inhalation of prostacyclin for more selective pulmonary
effects. But because of its short duration of action it must be inhaled 6-12 times daily
(Olschewski et aL, 2002; Hoeper etaL, 2000).

To enhance prostacyclin benefits, combination therapeutic approaches and inhibiting
multiple pathways concurrently may produce additive benefit. Others have examined
combining a prostacyclin with agents that increase cyclic guanasine phosphate (cGMP). This
is accomplished by inhibition of the phosphodiesterase 5 enzyme (PDE-5) which degrades
cGMP in the vascular smooth muscle cell. The pulmonary vasculature has a higher
concentration of the PDE-5 enzyme than most vascular beds. Oral sildenafil in combination
with iloprost in (Hoeper et al, 2000) PAH patients over 9 to 12 months follow-up improved
exercise capacity and hemodynamics (Ghofrani et al^ 2003). Open uncontrolled experience
adding sildenafil to epoprostenol also improved hemodynamics (Stiebellehner et al^ 2003)
and open label addition to subcutaneous treprostinil improved exercise capacity (Gomberg-
Maitland et aL^ 2005). Large multicenter trials are currently in progress. Of note, animal
data obtained prior to the large scale epoprostenol plus sildenafiil study consisted of safety
and efficacy of sildenafil not the dmgs in combination. There is a reported animal study with
beraprost (oral formulation not approved in U.S) plus sildenafil using the monocrotaline rat
model that did not demonstrate any safety/toxicity and demonstrated efficacy and improved
survival (Itoh et al^ 2004). Previous sorafenib studies have not demonstrated known dmg
interactions with warfarin or digoxin. Patients on other classes of PAH therapy (endothelin

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receptor antagonists, m-ginine), or experimental therapies will not be included based on the
lack of conclusive data and on the preference to examine the drug in a homogenous patient
population.

PAH is a devastating disease. Ethically, for Phase I/II trials based on current
5 available therapeutic agents, the inventors believe that all subjects should have significant
exercise capacity limitation based on the 6MW and be receiving prostacyclin therapy with or
without sildenafil.

Patient Selection-Eligibility Criteria:

1 . Age >1 8 years

10 2, PAH as defined as IP AH, FPAH or PAH associated with connective tissue disease.

(Humbert et al^ 2004)

3. Baseline 6MW > 150 meters and < 450 meters

4. PAH as defined by hemodynamics at diagnosis by right heart catheterization
defined as: mean PAP >25 mmHg with a normal PCWP <15 mm Hg at rest and a PVR >2

15 Woodimits

5. Receiving conventional therapy as clinically indicated (oxygen, diuretics,
aldosterone antagonist, calcium channel blockers, digoxin) with dose that is unchanged in the
preceding 30 days prior to enrollment. This is excluding anticoagulants (warfarin) as the
patient^s dose may not be stable if the patient is having a cardiac catheterization at baseline

20 within 30 days of enrollment and warfarin is being held. The dose of warfarin needs to be
stable for 7 days or therapeutic with an rNR=2.0

6. On intravenous/subcutaneous prostacyclin at a stable dose > 30 days

7. Subjects must be on sildenafil at a stable dose >30 days,

8. Must have right heart catheterization on prostacyclin + sildenafil within preceding
25 30 days. Subjects must be on a stable dose of medication within 30 days prior to cardiac

catheterization and therefore there can be no dosage changes of the medications between
catheterization and baseline.

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9. Must have pulmonary function tests (PFT) within 90 days prior to enrolhnent:
TLC, FEVl, FVC, DLCO

10. Women of childbearing years must use adequate contraception (hormonal or
barrier method of birth control) prior to enrollment

5 11. Ability to understand and the willingness to sign a written informed consent

document

Exclusion Criteria:

1, PAH associated with all other etiologies: HIV, portopulmonary disease,
congenital heart disease (Humbert et al^ 2004)

10 2. Subjects with pulmonary hypertension due to thromboembolism, significant

interstitial lung disease, chronic obstmctive pulmonary disease, congestive heart failure,
valvular heart disease (Humbert et aL, 2004)

3. Subjects with (World Health Organization (WHO) functional Class IV (Humbert
et al, 2004)

15 4. Subjects with scleroderma with total limg capacity (TLC)< 60% of predicted

within 30 days of screening

5. Subjects with significant obstmctive lung disease with FEVl < 80% of predicted

6. Subjects with hypotension defined as systolic arterial pressure < 90 xnmHg at
baseline

20 7. Subjects with hypertension defined as systolic arterial pressure >140 mmHg at

baseline and a diastolic arterial pressure > 90 mmHg.

8. Subjects with impaired renal function as defined as creatinine clearance <30
ml/min as defined by the Cockcroft-Gault formula: Male: Creatitine clearance (ml/min)=
(140-^age) X (body weight in kg)/ (72x serum creatinine in mg/dl); Female: Creatitine

25 clearance (ml/min)= 0,85 (140-age) x (body weight in kg)/ (72x serum creatinine in mg/dl)

9, Subjects with liver function tests (transaminases (AST/ALT), total bilimbin, and
alkaline phosphatase) >2X normal values

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10. Subjects with, acutely decompensated heart /faitoe or hospitalization within the
previous 30 days prior to screening

1 1 . Subjects may not be receiving any other investigational agents

12. Subjects on endothelin receptor antagonists (bosentan, sitaxsentan^ ambrisentan)
5 or chronic arginine supplementation

13. Subjects with left ventricular ejection fraction <45% or left ventricular shortening
fraction <0.2

14. Subjects with acute myocardial infarction within 90 days prior to screening

15. Subjects with limitations to performance of exercise measures (6MW) due to
10 conditions other than PH associated dyspnea/fatigue

16. Subjects taking nitrates for any medical problem

17. Subjects taking phosphodiesterase inhibitors (any formulation) for erectile
dysfunction

18. Subjects with a recent (<180 days) history of pulmonary embolism verified by
15 ventilation/perfiision scan, angiogram or spiral CT scan

19. Pregnant or lactating women

20. Subjects with a history of current drug abuse including alcohol
Treatment Plan:

Each subject will be individually dose escalated to a maximum of 400 mg twice daily.

20 The starting dose of sorafenib will be 200 mg daily. If tolerated at the completion of 1
month, the dose will be increased to 200 mg twice daily. If dose-limiting toxicity (DLT)
occurs, dose escalation will be terminated and that dose level will be denoted as the
maximum administered dose (MAD) for this subject. The subject will continue on the dose
preceding the last escalation to complete a total of 4 months of active therapy. If this dose is

25 not tolerated the subject will be withdrawn. If 200 mg twice daily is tolerated at the
conclusion of month 2, the dose will be increased to 400 mg twice daily. If 400 mg twice
daily is tolerated at the end of month 3 it will be continued until the completion of month 4.

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Dose Limiting Toxicity (DLT) is defined as intolerable prostacyclin side effects:
flushing, headache, nausea, loose stool, jaw discomfort with "first bite'\ and foot pain with
prolonged standing or walking. Intolerable side effects from phosphodiesterase inhibitors:
headache, gastrointestinal distress, hypotension. Intolerable side effects from sorafenib: rash^,
5 diarrhea, fatigue, hypertension, hand-foot syndrome.

Grading of DLT will occur on a 3 point scale for prostacyclin and phosphodiesterase
side effects: 1 = stable, 2 = increased but tolerable, 3 == increased -f- intolerable. Prostacyclin
dose will not be down-titrated for any reason in this investigational trial. If this is required
the subject will be withdrawn.

10 Grading of DLT for sorafenib will be based on the Common Temiinology for

Adverse Event oncology grading scale 1-5. (CTAE V3. 0-1 2/1 2/03). The three most common
adverse events include diarrhea and hand-foot skin reaction with the following grading:
Diarrhea: 1 = increase of < 4 stools per day over baseline, 2 = increase of 4-6 stools per day
over baseline; IV fluids indicated < 24 hours, 3 — increase of > 7 stools per day over baseline;

1 5 incontinence; TV fluids >24 hours; hospitalization^ 4 = life threatening consequences, and 5 =
death. Hand-foot skin reaction: 1 = minimal skin changes or dermatitis (e,g. erythema)
without pain, 2 = skin changes (e,g. peeling, blisters, bleeding, edema) or pain, not interfering
with function, and 3 ~ ulcerative dermatitis or skin changes with pain interfering with
function. H3/pertension: 1 = asymptomatic, transient (<24 hours) increase by >20 nrniHg

20 (diastolic) or to 150/100 mmHg if previously normal; intervention not indicated, 2 = recurrent
or persistent (>24 hours) or symptomatic increase by >20 nmiHg (diastolic) or to >150/100
mmHg if previously normal; monotherapy may be indicated, 3 = requiring more than one
drug or more intensive therapy than previously, 4 = Life threatening consequences (e,g,
hypertensive crisis), 5 ~ death. Subjects will be withdrawn with CTAE grade 3 diarrhea,

25 hand-foot skin reaction, or hypertension.

DLT Cardiovascular/PH toxicity is defined as arrhythmia, worsening right heart
failure, hospitalization for worsening right heart failure/PH, worserdng dyspnea, worsening
WHO class, worsening exercise capacity as defined as a decrease in 6MW >20% firom
baseline or a decrease of >30 meters with subjective or clinical signs and symptoms of
30 progression.

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Expected Adverse Events (AE): Prostacyclin side effects: include flushing, headache,
naxisea, loose stooU jaw discomfort with "first bite", and foot pain with prolonged standing or
walking. Sildenafil side effects: gastrointestinal discomfort, headache, flushing. Sorafenib
side effects: rash, diarrhea, fatigue, hypertension, hand-foot syndrome.

5 Withdrawal: Subjects withdrawn from protocol due to clinical deterioration or DLT

will have an office visit 30-40 days after end of treatment to record the following: physical
exam, blood pressure, PH symptoms, WHO class, concomitant medications/adverse events,
dose of prostacyclin, 6MW and TT.

Data Safety Monitoring: Weekly meeting by the PH research team will discuss all
10 subjects enrolled for data safety monitoring.

Data Collection: Subjects will have a screening visit prior to enrollment including a
history and physical exam. At this visit subjects will have two-6MW with Borg Dyspnea
Score (B) >2 hrs apart up to 1 day later, as per ATS guidelines, using phrases of standard
encouragement (ATS statement, 2002). The second test will be used for screening purposes

15 and to limit variability. The mean reported increase ranges from 0 to 17% preformed a day
later (ATS statement, 2002). Alternatively this can be done on separate days within 14 days.
All patients will have an assessment of WHO functional class, and if needed PFT and a right
heart catheterization as stated by the protocol. WHO functional Class is defined as: Class I:
no limitation of physical activity, no symptoms of chest pain, angina, dyspnea, or near

20 syncope with ordinary activity. Class 11: slight limitation of physical activity, ordinary
physical activity causes dyspnea or fatigue, chest pain, or near-syncope. Class III: marked
limitation of physical activity, less than ordinary activity causes dyspnea or fatigue, chest
pain, or near-syncope, and Class IV: inability to perform activity without symptoms, signs of
right heart failure, dyspnea and or fatigue at rest, and discomfort is increased by any physical

25 activity (Humbert et al, 2004). These screening tests will be counted as their baseline test
results.

If the subjects meet criteria for enrollment they will return for the formal baseline visit
approximately 14 days from screening. At this time they will have a 6MW/B followed by TT
(unencouraged) >1 hr apart (Gomberg-Maitland et al, 2005; Patterson et al, 1972) a 2DE to
30 assess TR velocity, a 3DE examination (experimental endpoint), and CT (experimental
endpoint). Subjects will be seen weekly for safety evaluation with a clinical exam and

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documentation of WHO classification. Safety evaluation will include the following data:
adverse events related to sorafenib toxicity, related to prostacyclin side effects, and related to
phosphodiesterase inhibitor side effects. Each month, all subjects will have both a 6MW and
TT as per protocol^ laboratory including: CBC with differential, BCP (serum sodium), LFT
5 (including albumin), uric acid, INR, BNP, troponin I, bFGF, and then be seen in the office to
evaluate further dosing of sorafenib.

At month 4 subjects will be required to be seen on 2 consecutive days. Day 1 subjects
will have an office visit, a baseline 6MW/Borg score, an assessment of WHO fimctional
class, a TT, PFT, 3DE, and CT. Day 2 will be a right heart catheterization.

10 Hemodynamic values will be determined by serial measurements of hemodynamic
parameters (specifically CO and mPAP) to demonstrate stability. Stable hemodynamics are
defined by changes in CO and mPAP of less than or equal to 20% between three consecutive
serial measurements at least 5 minutes apart. After hemodynamic stability is demonstrated,
the hemodynamics and oxygen saturation variables from the last assessment will be recorded.

15 Safety endpoints at month 4 will include: time to clinical worsening defined as death,

lung transplantation, hospitalization due to PH/right heart failure, a decrease in exercise
measures by at least 20% compared with baseline measure, worsening hemodynamics: either
an increase in mean PA pressure by >20%, an increase in PVR > 20%, and or a decrease in
CO by >20%, and worsening PFTs as evidence by a decrease in DLCO, FEVl, FVC, or TLC

20 by >15%. Preliminary efficacy endpoints will include: monthly 6MW/B, WHO functional
class, TT (experimental), 4 month right heart catheterization, TR velocity on 2DE, 3DE to
assess RV parameters, (experimental)^ and a 64 slice CT (experimental).

Follow-Up: At the conclusion of 4 months, subjects with perceived benefit as
evidenced by objective and subjective measures based on the determination of the principal
25 investigator and the sponsors and advisors on the grant will continue on therapy at their
month 4 dose up to 1 year of therapy. They will continue to have follow-up visits every 3
months with a 6MW test to a maximum of 1 year. They will be expected to speak with a
member of the PH team to discuss AEs monthly by phone and all serious adverse events
(SAE) will be reported to the PI and the IRB throughout the duration of the study.

30 B. Single center Phase II trial of sorafenib in PAH patients.

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Objectives Phase II study: Objectives are to assess safety and efficacy endpoints of
sorafenib by a randomized discontinuation design. This is a 2 center study with a placebo
controlled study using a randomized discontinuation design: placebo or MTD based on Phase
IB study

5 Accrual: Estimated 22-88 patients. Enrollment will be completed in 18-24 months—

tliis will be based on preliminary efficacy firom Phase EB.

Patient Selection: Eligibility and Exclusion Criteria as in Phase IB.

Treatment Plan:

Phase II will begin with a dose titration to the MTD based on the escalation described
10 above; a 12-week open label run-in period. This will begin with a dose titration to the Phase
IB MTD based on a titration regime of tolerance from the Phase IB study. If a subject does
not tolerate any dose prior to the MTD or 1 month of MTD they will be withdrawn; not
I'andomized into the placebo controlled study. Subjects with worsening 6MW > 20% with
worsening fiinctional class or signs/symptoms of deterioration will be withdrawn firom the
15 study. After the 12-week rua-in period, disease status will be assessed based on change in
6MW distance. Subjects with > 50% improvement or > 100 meter improvement will
continue to receive sorafenib until disease progression or toxicity, in order to avoid potential
ethical concerns about randomization of patients with apparent major clinical benefit. The
inventors do not expect a withdrawal for clinical deterioration with sorafenib but since this
20 occurs with prostacyclin it will be a potential risk. These patients will be followed as per
standard of care every 3-6 months.

The remaining patients without obvious treatment benefit or failure during the open-
label run-in period will be randomized in double-blind fashion using a central allocation via a
telephone randomization system to receive the same dose of sorafenib or placebo. Evaluation

25 of these subjects will be as per the Phase IB plan with weekly safety and monthly efficacy
evaluations. Subjects with worsening 6MW > 20% with worsening fiinctional class or
signs/symptoms of deterioration will be miblinded. If on placebo they will receive sorafenib
at their previous dose; if on active drug they will be withdrawn. Those subjects who have a
decline in 6MW without worsening clinical signs or symptoms will be seen at the next week

30 visit and the 6MW will be repeated (unless there is evidence of clinical deterioration); this is
to address the variability of the test and the variability of the individual. If the repeat 6MW

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still demonstrates deterioration^ the subject will be imblinded to therapy and treatment will be
as above: if on placebo they will receive sorafenib at their previous dose; if on active dn.ig
they will be withdrawn. DLT criteria will be followed as per Phase IB at weekly visits.

Data Collection:

5 Subjects will be followed as per Phase IB with the following differences: 1) If

subjects have clinical deterioration at any time after randomization, defined as 6MW > 20%
decline with clinically assessed deterioration, or clinically assessed progression, they will be
unblinded as per protocol. Subjects on placebo will be offered sorafenib at their previous
dose, and subjects on active therapy, sorafenib will be withdrawn from study. 2) All subjects
10 unblinded and started on active therapy will have a right heart catheterization after 6 months.

"Withdrawal:

Subjects withdrawn from protocol due to clinical deterioration or DLT will have an
office visit 30-40 days after end of treatment to record the following: physical exam, blood
pressure, PH symptoms, WHO functional class, concomitant medic ations/AEs, dose of
15 prostacyclin, 6MW and TT.

Statistical Analysis:

Based on the efficacy data: improvement in * 6M W at 4 months on MTD a power
calculation will be made to determine the sample size needed for this trial. The case report
with combination therapy with imatinib at 3 and 6 months demonstrated a 60% improvement

20 in 6MW. It is estimated that the sample size conservatively based on previous therapeutic
trials to a maximum of 60% based on this report. A better estimate will be obtained based on
Phase EB trial. For example, assuming a 30% improvement in 6MW5 with 80% power, the
estimated sample size is 39 subjects in each arm, a 40% improvement 23 subjects in each
arm, and a 50% improvement =15 subjects in each arm and a 60% improvement = 10

25 subjects in arm. The investigators will allow for a 10% drop-out rate and adjust the sample
size accordingly. An early stopping mle, using the O'Brien Fleming alpha spending rule,
using an a of 0.0003 leaving p=0.0497 after 35% of subjects enroll (subject to change based
on efficacy from IB). The trial will be stopped if the rate of deterioration at 3 months after
randomization is higher or lower than expected. The DSMB will determine if the trial need

30 to be stopped.

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Data Safety Motiitoring Board:

The DSMB will consist of the Sponsor, Co-Sponsor, members of the Scientific
Advisory Committee in addition to 2 outside PH specialists to be determined by the Principal
Investigator (PI).

5 EXAMPLE 5

Identification and initiation of early clinical trials of new agents in PAH

The Clinical Therapeutics in Pharmacology and Pharmaco genomics group are
informed of novel kinase inhibitors being evaluated by an oncology Phase I/II unit. As these
agents are evaluated in oncology patients^ tlaey will be assessed for potential benefits and
10 risks in PAH patients. If the agent scientifically has potential efficacy, the agent will be
evaluated in preclinical studies with the hypoxic/SU5416 rat model of PAH.

Studies will be designed as done with sorafenib, with 15-18 male Dahl-sensitive rats
weighing between 150 and 250 grams will be divided into 5 groups: normoxia + vehicle
(normal, healthy control), hypoxia + vehicle (hypoxia control), hypoxia + SU-5416 (positive

15 control), hypoxia + sorafenib (safety comparison with SU-5416)^ and hypoxia + sorafenib +
SU-541 6 (therapeutic activity assessment). All animal care and procedures will be preformed
in accordance with institutional guidelines. Animals are housed in a Plexiglas chamber open
to room air (normoxia) or maintained at 10% Fi02, Rats in the two SU-5416 groups will
receive one injection of SU-5416 at the start of the experiment (20 mg/kg). Agent will be

20 prepared for intraperitoneal lavage and dosed as per known rat protocols. Pressures and
echocardiography will be preformed as described herein and in the scientific literature. If rats
given the agent plus hj/poxia do not develop PAH and appear to have some therapeutic
activity (i*ats given SU5416 plus hypoxia^ plus agent), the inventors will proceed to Phase IB
study as described.

25 Phase IB studies will be designed as a small safety and tolerability study of the agent.

The study will determine the MTD and assess vital signs and clinical exam assessment at
weekly office visits. If the drug is tolerated with some preliminary efficacy, a Phase 11 study
will be initiated. The study will be a randomized discontinuation trial. If Phase I and Phase
II are not successful because subjects do not tolerate the medication based on severe DLT, or

30 with minimal efficacy the process will be reinitiated with a novel therapeutic agent.

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EXAMPLE 6

Additional Phenotvpic Markers

Treadmill test as new standard of care exercise measure. The inventors have begun
creating a new model using the data from the intravenous treprostinil study, based on the
preliminary data demonstrating that the treadmill test (TT) was similar to the 6MW, had
repeated reliability, and predicted functional class. The relationship between distance (DIST)
and MET was modeled using generalized estimating equation (GEE) models which
accoxmted for the within patients correlations since multiple measurements were conducted
for each patient. The inventors first fitted a piecewise regression using data between baseline
and month 3 (Model 1) and validated the model fitting using data between month 6 and
month 12. The data had a ''good" correlation, a "good fit" and thus the inventors were able to
develop a piecewise regression model with all data (Model 2). The new model appears to
differentiate less sick patients and is as good as the 6MW,

To completG analyses, the inventors will develop receiver operator curves accounting
for repeated measures to compare the 6MW to the TT. Based on this analysis, if TT is as
good as 6MW^ logistic regression analyses will be done on this data set to determine if MET
is a good predictor of clinical worsening, survival, and clinical outcome variables including
hemodynamics, echocardiography, and laboratory biomarkers. The model will estimate
predicted MET based on 6MW distance but does not predict MET based on the patient's
individual characteristics. At the University of Chicago, all patients have yearly TT
evaluations, and evaluations pre and post medication changes. Initially, the model will be
assessed in the University of Chicago dataset of patients having both the 6MW and the TT,
A prediction equation will be developed for the TT to determine MET expected for individual
PH patient based on WHO class. In addition, the inventors will be using the TT as an
experimental endpoint in all trials conducted.

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PCT/US2007/060995

Table. 4

Model 1: Model 2:

Piecewise regression Piecewise regression

Observed data (all with data 0-3 months with data 0-12 months

— mnnthci

1 1 1 1 LJI 1 LI 1 0

^M" J ^ f /

Mil' i }

s.Iope <4

107.1795

slope <4

110.3069

slope ^

19.12348

slope ^

19.37262

intercept

-31 .6585

Intercept

-42.90939

MET

mean DIST

MET

DIST

MET

DIST

176.0

183

178

288.4

290

288

395.8

397

398

415.1

416

418

442.2

435

437

460.1

454

456

476.9

474

476

423-5

493

495

513-8

512

515

545.5

531

534

3DE and CT scans as novel non-invasive measures. Continued preliminary data will
be obtained for both technologies. As development progresses, these measures will be linked
5 with clinical phenotype obtained from the PHC database. Surprisingly on 3DE the tricuspid
valve annulus does not dilate as expected with increasing RV size. Measures of RV 3D areas
will be compared with 2D imaging using Spearman rank correlations. Change in area as a
response to therapy will be recorded. TR velocity will be measured in 2DE. All of these
measiues will be evaluated based on clinical characteristics, response to therapy, and

10 outcomes to determine predictive value. Use of this modality in the evaluation of VEGF
inhibitors and other vascular signaling targets on the right ventricle and pulmonaiy artery in
our early drug development studies should prove to be a useful endpoint. For CT scans, the
University of Chicago ''s 64 detector CT scan will be used to implement routine chest CT on
all PH patients. The inventors contemplate using automated technology and advanced

15 detection to identify plexiform lesions and novel indices of PH severity. The goal is to detect
and then use the technology to follow response to therapy and as a possible screening tool.

Biomarker development. Blood samples will be obtained from all patients seen by the
PH program and stored for future evaluation of potential serum markers, genetic, and
proteomic evaluation. Concurrent with Phase I/II trials, biomarkers previously described will
20 be assessed: UFT (album.in)j uric acid, serum sodium, BNP, troponin I, bFGF, angiopoietin-2.
Response to therapy may also be linked to genetic profiles. The GCRC will help with the

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processing and storage of samples. A database has been created compliant with HIPPA
standards.

EXAMPLE 7

Sorafenib Relieves Pulmonary Vressnre

5 A3 week study was designed and executed to assess the safety and therapeutic

activity of sorafenib in a hypoxia-induced model of pulmonary hypertension in Dahl SS rats.
A compound with a reportedly more Hmited spectrum of kinase inhibitory activity- SU5416
was previously demonstrated to exacerbate pulmonary hypertension in the Dahl rat
hypoxemic model. As part of the spectrum of sorafenib pharmacologic activity overlaps
10 with SU5416, we performed this study to determine whether sorafenib had similar effects or
with additional mechanisms of inhibitory activity could counteract the effects of SU5416.

Fifteen Dahl Salt Sensitive strain rats were divided into 5 groups: normoxia + vehicle
(normal^ healthy control)^ hypoxia + vehicle (hypoxia control), hypoxia -f SU5416 (positive
control), hypoxia + sorafenib (safety comparison with SU5416), and hypoxia 4- sorafenib +

15 SU5416 (therapeutic activity assessment). Echocardiograms were performed on ail rats at the
start of the experiment. Except for the normoxia group^ all rats were maintained in a hypoxia
chamber with a partial pressure of oxygen of 10% Fi02 for the duration of the experiment.
Rats in the 2 SU5416 groups received one subcutaneous injection of SU5416 at the start of
the experiment (20 mg/kg). Stock sorafenib solutions were prepared every three days,

20 crushing and dissolving sorafenib tablets in EL/ethanol (50:50; Sigma Cremophor EL, 95%
ethyl alcohol) at final concentration of 4 mg / mL, protected trom light exposure and stored at
room temperature. Final dosing solutions were prepared on the day of use by dilution of the
stock solution to 1 mg/mL with water and administered by gavage to the rats daily. After 3
weeks, all rats had echocardiography and hemodynamic studies. Organ and blood specimens

25 were obtained for furtlier evaluation.

As has been previously described, rats given SU5416 developed pulmonary
hypertension measured by elevated right ventricular and pulmonary artery pressures,
echocardiographic changes, and elevated right ventricle/Iefl ventricular weights. Rats
exposed to h3^oxia had mildly elevated pressures compared with nomioxia and there was no
30 significant change in pressures or weights in rats given hypoxia plus sorafenib. Sorafenib
appears to have a beneficial effect on pulmonary hypertensive rats as rats in hypoxia, plus

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SU5416, plus sorafenib had pressures and weights similar to normoxia. Table 4. The small
sample size did not allow for significant change in echocardio graphic data but there appeared
to be a positive trend with this combination.

Sorafenib appears to protect SU5416 treated hypoxia-exposed rats jErom pulmonary
5 arterial hypertension. Furthennore, while sorafenib and SU5416 share some pharmacological
activity, unlike SU5416, sorafenib does not exacerbate hypoxia-induced hypertension. Based
on these results the inventors repeated the experiment with 1 8 rats distributed in the same 5
groups (only difference was 3 additional rats in the normoxia control group). The results were
reproducible. In the initial experiment two rats died during induction of anesthesia (after
10 unblinding normoxia , Hypoxia/SU5416). In the subsequent experiment, one rat died on day
zero (after unblinding hypoxia/SU5416).

Sorafenib appears to protect SU5416-treated hypoxia-exposed rats jGi-om pulmonary
arterial hypertension. Furthermore, while sorafenib and SU5416 share some pharmacological
activity, unlike SU5416 sorafenib does not exacerbate hypoxia-induced hypertension.

wo 2007/087575

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8.80±5.94

6.80

230i0.71

5.63±4.07

W-)

CI (PA)

•

1 — 1

-H
m
est

r<i

CD
-H

T— *

1 1

1.16±0.30

1.12±0.16

1.21±0.26

0.87±0.14

1.70±1.43

0.82±0.17

0,94db0.49

1.12±0.27

CO (PA)

736±478

CD
CO

406±115

oo
<^

400±99

279±69

551±467

271±48

vo
vo

CO
CO

CD
1 — t

ON
WO
CO

8.75±0.64

o
cs

4.43±1.78

3.65±2.76

CN
0\

-H
vo

CO
1 — 1

3.87±0,95

2.00±1.18

3.80±1.41

MPA

0.45±0.05

0.43±0.05

0.40±0.03

0.45±0.01

0.41±0.05

OO
CO

0.38±0,07

■1 — (

41
CO

0.45±0.04

CI (Ao)

1.49i0.11

1.00±0,09

1.14±0.15

0.91±0.35

0.95±0.06

CN
CN

1 — t

4i
t —

1.00±0.80

0.74±0.19

CO (Ao)

500±29

OO
CO

397±36

OO
t — I

CN
CO

310±10

wo
wo

^ H

r-
wn

CN
CO

WO
vo

41
t —

LV Mass
(gram)

VO
CD

•

CD
WO

•

1.50±0.44

1 — t

-H
oo
o

CD
CO

■

CO
CO

CD
CO

"n
O
VO

y—i
CD

•

0.93±0.05

FS (%)

4H
wo

68±4

79±3

^ 1

71±11

CO
vo

4i
oo

1 — I
1 — (

75±14

0.24±0.06

CN
O

0.24±0.10

O.I6±0,02

CD
C?

1 — f
CO

0.16±0.02

<o
^[

4i
1 — 1

0,18±0.03

0.22±0.04

0.20±0.04

RVAW

1 — 1
CD

T" ■!

0.14

0.07

0.16±0.03

t — t
O

0.09

O.lliO.Ol

Wt(g)

337±19

VO
VO

350il4

353±25

r — I

oo
CN

V— I

oo
CN
CO

331±15

CO
CO

4?
oo

Nomioxia-PRE

(n=3)

Normoxia-
POST (n=2)

hypoxia-PRE

hypoxia-POST
(n=3)

CO ci

4- ^ —

CO cit

<^ ^

O F=J

CQ ■'

>3 CO

CO li

S vo

sorafemb+SU54
16-POST (n=3)

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The following references, to the extent that they provide exemplary procedural or
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U.S. Patent 5,567,434

U.S. Patent 5,580,579

U.S. Patent 5,641,515

U.S. Patent 5,725,871

U.S. Patent 5,738,868

U.S. Patent 5,741,516

U.S. Patent 5,756,353

U.S. Patent 5,780,045

U.S. Patent 5,792,451

U.S. Patent 5,795,587

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CLAIMS

1 . A method comprising providing sorafenib to a subject with pulmonary arterial
hypertension (PAH), with symptoms of PAH, or at risk for PAH.

2. The method of claim 1, wherein the subject is provided with sorafenib by
administering or prescribing to the subject sorafenib, a sorafenib prodmg, or a
pharmaceutically acceptable salt thereof.

3. The metliod of claim 1 ^ fiortlier comprising identifying a subject with PAH or
symptoms of PAH.

4. The method of claim 3^ wherein the subject is diagnosed as having severe PAH.

5. The method of claim 1^ wherein the patient has a mean pulmonary artery pressure
equal to or greater than 25 mm Hg with a pulmonary capillary or left atrial pressure equal to
or less than 15 mm Hg,

6. The method of claim 1, further comprising evaluating PAH in the subject.

7. The method of claim 6, wherein the patient is evaluated before and/or after
administering the composition.

8. The method of claim 6, wherein the subject is evaluated for PAH by having an
electrocardiogram, an echocardiogram, pulmonary function tests (PFTs), a perfusion lung
scan^ and/or a right-heart cardiac catheterization.

9. The method of claim 1, wherein the subject is provided multiple doses of sorafenib.

10. The method of claim 9, wherein a dose is between about 5 and about 500 mg of
sorafenib or a sorafenib prodrug.

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1 1 , The method of claim 2, wherein the sorafenib or sorafenib prodrug is administered or
prescribed for administration orally, intravenously, intraarterially, inhalation.

12. The method of claim 1, further comprising providing at least a second PAH treatment.

13. The method of claim 12, wherein the second treatment is an anticoagulant, an calcium
chaimel blocker, a prostacyclin, Bosentan, nitric oxide. Sildenafil, a diuretic, a cardiac
glycoside, a vasodilator, an endothelin antagonist, a phosphodiesterase inhibitor, an
endopeptidase inhibitor, a lipid lowering agent, a thromboxane inhibitor, or oxygen.

14. The method of claim 1, wherein the sorafenib is provided before, after, or during
surgery.

1 5. The method of claim 14, wherein the surgery comprises lung transplantation.

16. A method of reducing pressure in the puhnonary artery of a patient comprising
administering to the patient an effective amount of a composition comprising sorafenib, a
sorafenib prodmg, or a pharmaceutically acceptable salt thereof

17. A method for treating or preventing PAH in a patient comprising administering to the
patient an effective amount of sorafenib, a sorafenib prodmg, or a pharmaceutically
acceptable salt thereof.

18. A pharmaceutical composition comprising (a) sorafenib or a sorafenib prodrug and
(b) at least a second PAH treatment.

19- The pharmaceutical composition of claim 18, wherein the second PAH treatment
comprises an anticoagulant, an calcium channel blocker, a prostacyclin, Bosentan, nitric
oxide, Sildanefil, a diuretic, a cardiac glycoside, a vasodilator, an endothelin antagonist, a

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phosphodiesterase inhibitor, an endopeptidase inMbitor, a lipid lowering agent, or a
thromboxane inhibitor.

20. A method comprising providing a VEGFR2 inhibitor to a subject with pulmonary
arterial hypertension (PAH), with symptoms of PAH, or at risk for PAH.

21 . The method of claim 20, wherein the VEGFR2 inhibitor is selected from abt-869,
amg706, AZD217U bay57-9352, sorafenib, XL647, XL999, GW786034, bevacizumab,
PKC412, AJEE788, PTK787 (vatalanib), OSI-930, OSI-817, SU11248, AG-013736, ZK3-
4709, quinazoline ZD6474, pyrrolocarbazole CEP-7055, or CP-547632.

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4®i

fell'

H Normoxia

H Hypoxia

Q Hypoxia +
SU5416

Hypoxia +
SUS416 +
Sorafenib

Hypoxia +
Sorafenib

FIG. lA

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40 -

■35

Z3nii

25 -

20 -

15 -

10 -

5 -

0 ■

Pulmonary Artenai Pressures

Vehicle

-',''•7-"

Sorafenib

^p<0.01;n=6

Norm Hypoxia Hypoxia Hypoxia

+ SU5416

Hypoxia
+ SU5416

FIG. IB

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E
E

35 -

o: 15

m Normoxia

□

Hypoxia

D Hypoxia +
SU5416

Hypoxia +
SU5416 +

Sorafenib

Hypoxia +
Sorafenib

FIG. 2

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50
45
40
35
30

20
15
10
5
0

■Jr--

^^^^^

lii

H Normoxia

Hypoxia

n Hypoxia +
SU5416

□ Hypoxia +
SU5416 +
Sorafenib

Hypoxia +
Sorafenib

FIG. 3

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.2 0.3

0.45

0.4

0.35

0.25

0.2

0.15

0.1

0.05

Normoxia

Hypoxia

□ Hypoxia +
SU5416

□ Hypoxia +
SU5416 +
Sorafenib

Hypoxia +
Sorafenib

FIG. 4A

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Right Ventricular Hypertrophy

0.5 ^
0.45

0.4
0.35 J

0.3 -
0.25 _

0.2 .
0.15 -

0.1 -
0.05

^p<0.01

p<0-01
Sorafenib

Normoxia

Hypoxia Hypoxia + Hypoxia Hypoxia +

SU5416 SU5416

FIG. 4B

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140

120

100

60 -i

"^.;j;,-;v;jVrf ij.^

■'"■•3,

in Normoxia

Hypoxia

n Hypoxia +
SU5416

□ Hypoxia +
SU5416 +
Sprafenib

Hypoxia +
Sorafenib

FIG. 5

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LV Mass (g)

2,50

2.0D

1.50

1.00

0.5O

Q.0O

0mm

'i?" -.-fit' ,

ills

^ ^*C*^rs;.Tf *^ ;

ft -■rSM-'j'

NML- NML-
pre post

HYP- HYP-
pre post

HYP HYP

+ +

SOR- SOR-

pre post

HYP HYP

+ +

SU5416 -
pre posi

HYP HYP
+ 4,

SOR SOR

SU5416
pre post

FIG. 6

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Aortic Cardiac Output (l/min)

1200.00

1000.CX)

800.00

600.00

400.00

200.00 -

0,00

Jit J ^r^ 'trinJ

'*^*-i^v-i*j:'i

.V-

--^irf*'"^*--" -'i^ii V;5 ;'iii J

NML- NML-
pre post

HYP- HYP-
pre post

HYP HYP

SU5416
pre post

HYP

SOR SOR

SUS416
pre post

FIG. 7

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PA Pressure Gradient (mm Hg)

14.00

12.00

1O.00

8,00

6.00

4.00

2.00

0.00

^-J'^

d. ■-is;.;^,^,;^t^,■

. '-^

0,!-it-,(-i; „ :-

NML- NML-
pre post

HYP- HYP-
pre post

HYP + HYP +
SOR- SOR-
pre post

HYP 4- HYP +

SU541S

HYP + HYP +
SOR SOR

SU5416
pre post

FIG. 8

wo 2007/087575

11/17

PCT/US2007/060995

RV free wall thickness (cm)

0.2 1

o.ia

0.16

0.14

0.1

o.oa

G.06

0.O4 .

ao2

.lit);. -jriiT,

; | ,^.^; i ^tj.;

.^.mi H ji* 1^^.

'IS

^ ^-^^jf

• ' ' ^^^^^^♦^^.•'Vji^ ^^^^^^^^

iJ,,,(!J,.._t>.

i-v-i.'iSJr.vii.-*;

ftij^jj

NML- NML-
pre post

HYP- HYP-
pre post

HYP + HYP +
SOR- SOR-
pre post

HYP + HYP +

SU5416 •
pre post

HYP + HYP +
SOR SOR

+ +
SU6416

pre post

FIG. 9

wo 2007/087575

12/17

PCT/US2007/060995

PA Pressure (mm Hg)

14.00

12.00

10.00

8,00

6.00

4.00

ZOO

0.00 1^

NML-post

Hyp+

SUS4^6pre

Hyp+Sor+
SU5416 post

Hyp i-Sor+
SU5416 pre

IIyp+Sor+
SU5416 post

FIG. 10

wo 2007/087575

13/17

PCT/US2007/060995

RV thickness (cm)

Q,2

ai8

OAS

0.14

ai2

O.00

O.06

0.04

O02

. ,iS#'*^3JT.^,1'-•■^,^i^i -, l>i ■ii

NML-post NML-posl

Hyp+

SU5416Dre

Hyp+Sor+
SU5416 DOSt

Hyp+Sor-f-
SU5416 pre

Hyp+Sor+
SU5416post

FIG. 11

wo 2007/087575

14/17

PCT/US2007/060995

FIGs. 12A-12B

FIG. 13

wo 2007/087575

15/17

PCT/US2007/060995

Imatinib ("2O0 mg/da)')

Combination !tlierap<>''witli iloprost.
sildenafil, and bosenitari

FIG. 14

FIG. 15

wo 2007/087575

16/17

PCT/US2007/060995

17/17

PCT/US2007/060995

3
CO

LL.

ZZZ! ajEZ

9 opBJO
9 epejo

Z epB4o
I, epejo
t/O apejo

0 ©PBJQ

UD ^ CO CN

sieuiiuv #

^^^^^

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